COVID-19 Vaccination and Symptom Reporting Form
Please answer the questions below before attending any NPH in-person events in 2023. To prioritize everyone's health and safety, we ask that all attendees provide proof of vaccination and report any symptoms or exposure before the gathering. 

To protect our community, all participants are required to

  1. Provide proof of vaccination prior to attending the event Note: If you have not been vaccinated and wish to do so in order to attend an NPH-sponsored event, please make sure your dose is administered at least 2 weeks prior to the event date. All vaccines administered prior to the 2 weeks mark will be accepted. 

  2. Wear a KN95, KF94, or N95 mask while not actively eating or drinking, and 

  3. Stay at home if you test positive for COVID-19, have COVID-like symptoms, or have recently been exposed. 

Additionally, we are urging participants to please take an at-home COVID test 24 hours before attending the event and to maintain physical distancing throughout the event when possible. 

Non-Compliance: Attendees who are unable or unwilling to comply with this policy are asked not to participate.

If the answer to any of the following questions is "Yes," please stay home.
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Email *
Today's Date *
First and Last Name *
Have you tested positive for COVID-19 within the last 14 days? *
Have you had close contact with anyone who tested positive for COVID-19 within the last 14 days?
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Are you experiencing any new or different symptoms that are not related to a pre-existing condition such as: Fever, Cough, Severe headache, Sore throat, Loss of taste or smell, Difficulty breathing/Shortness of breath, Vomiting/Nausea or Diarrhea, Runny nose, or Fatigue or Body Aches? *
To attend this event, we are requiring proof of vaccination. By checking this box you are stating that you are fully vaccinated and will bring proof to the event. Your registration/attendance confirms your consent to these terms.

Thank you for filling out the form and please contact Ja'Nai with any questions.
A copy of your responses will be emailed to the address you provided.
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