COVID-19 Self-Reporting Form
Submission Type *
Nature of this report *
Symptoms Experienced *
Are you currently experiencing or have you experienced within the past 7 days any of the following symptoms?
Yes
No
Fever (over 100.4)
Chills
Coughing
Shortness of Breath
Muscle Aches
Sore Throat
Lost sense of taste/smell
Newly developed headaches
Have been seen by medical professional
ENTER THE AFFECTED PARTY'S INFORMATION BELOW
Full Legal Name *
Enter YOUR full legal name below.
Phone Number *
This should be a number we can reach you at within 4 business hours of submission. Please enter your number in the following pattern: (xxx) xxx-xxxx
Email Address *
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