Anderson/Explorations Daily Survey
Email *
What is your first name? *
What is your last name? *
What is your role? *
Where are you located today? *
Do you have a fever equal to or higher than 100.0 degrees Fahrenheit or respiratory symptoms such as new or worsening cough, shortness of breath, sore throat, chills, repeated shaking with chills, body aches, muscle pain, headache, or new loss of taste or smell, headache, diarrhea, nausea or vomiting, and runny nose? *
In the past 14 days, have you had a potential exposure to a person with COVID-19? A potential exposure means a household contact or having close contact within 6 feet of an individual with confirmed or suspected COVID-19 for at least 10 minutes. The timeframe for having contact with an individual includes the period of time of 48 hours before the individual became symptomatic *
In the past 14 days, have you visited any of the states listed in the DOH’s travel advisory? If so, it is recommended that you quarantine for 14 days upon return. *
Have you tested positive for COVID-19, have a test pending for COVID-19, or been told by a medical provider that you may or do have COVID-19? *
Never submit passwords through Google Forms.
This form was created inside of Montgomery County Intermediate Unit. Report Abuse