Covid questionnaire
Email address *
Name *
Date of birth *
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Have you or anyone in your household traveled outside New York State in the last 14 days? *
Are you or anyone in your household experiencing a cold or any flu-like symptoms including fever, cough, shortness of breath, nasal congestion, runny nose or sore throat? *
Are you experiencing any nausea, vomiting or diarrhea? *
Have you or anyone in your household been told they were exposed to COVID-19 in the last 14 days? *
Have you or anyone in your household been quarantined because of COVID-19 in the last 14 days? *
If you answered yes to any of the above questions, please use the space below to explain.
Please use the space below to explain. express any other pertinent information regarding COVID-19. *
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