Name: (First and Last)
Date of Birth:
If you are applying to work as a pair with someone you reside with please list their name here:
Please note: Both participants must fill out a separate from and list their partner.
If you are applying to work with a group (company, team, etc) please list the organization name here:
Have you had any of the following symptoms in the last 7 days?
Shortness of breath
None of the above
In the last 14 days, have you had contact with anyone who tested positive for SARS-CoV2 (the virus that causes COVID-19), or anyone was told to isolate themselves because of possible COVID-19 exposure?
Do any of the following conditions or statements apply to you, which may increase your risk for severe illness from COVID-19?
Asthma, COPD, diabetes, HIV, age over 65, heart problems, kidney disease, liver disease, currently smoking, ongoing treatment for cancer (any type), immune deficiency disease, taking immunosuppressants (medicines that suppress the immune system for a chronic condition including steroids), BMI over 40, live or work in a nursing home, caretaker of a person over age 65, or caretaker of someone who has any of the criteria listed above. Please mark yes if any of these apply, even if you have a medical condition that is well-controlled.
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This form was created inside of Face Shield Project.