Fusion Core COVID-19 Self-Assessment for October 10, 2020
Please fill out this form if you plan to join us for our in-person Open House on October 10, 2020
Email address *
Last name of participant *
First name of participant *
Relationship to participant *
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? *
Have you or anyone in your household been tested for COVID-19? *
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *
Have you or anyone in your household traveled in or outside the U.S. in the last 21 days? *
If you traveled in the last 21 days, where did you go? Please answer 'N/A' if you did not travel in the last 21 days. *
Are you or anyone in your household a health care provider or emergency responder? *
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19? *
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19 in the last two weeks? *
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