COVID-19 Safety Screening
MPB Group
Sign in to Google to save your progress. Learn more
Client's Name: *
Today's Date: *
1) Have you or anyone in your household had any of the following symptoms in the last 14 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? *
2) Have you or anyone in your household/close proximity tested positive for COVID-19? If so, what date? What were the follow up precautions taken: (i.e. 14 day quarantine, tested yourself as a result?) *
4) Have you or anyone in your household traveled outside of the Country or on a cruise ship in the last 14 days? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of MPB Group, Inc.. Report Abuse