ICD Daily Visitor Health Questionnaire
Email address *
What is the FULL NAME of the individual completing this form? *
Please list the FULL NAMES of each person in your party (children and adults).
Have you or anyone else in your party experienced any of the following COVID-19 symptoms in past 14 days: fever, chills, cough, shortness of breath/difficulty breathing, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, new loss of smell or taste? *
Have you or anyone else in your party had a positive diagnostic COVID-19 test in past 14 days? *
Have you or anyone else in your party had close contact (within 6 feet for 10 or more minutes) with a confirmed or suspected COVID-19 case(s) in past 14 days? *
Have you traveled to a high infection area for COVID-19 anywhere in the US (i.e., state with widespread community transmission per the New York State Travel Advisory) or internationally within the last 14 days that would require quarantine? *
I endorse that all of my responses are true at the time of completing this form. I understand that if I answered YES to experiencing ANY COVID-19 symptoms, OR if I answered YES to having a positive COVID-19 test in the past 14 days, OR if I answered YES to having close contact with a confirmed or suspected case of COVID-19, that I and my party will not be able to enter the ICD building and I will need to reschedule my visit by calling 777-2829. By typing my full legal name below, I confirm the health status to the best of my knowledge of myself and my party by electronic signature. *
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