SHUFFLES - Daily Health Check
Please provide answers to the following questions.

In the past 14 days have you experienced any of the following:
Name *
Date *
A fever (100 degrees F or higher)? *
A cough or shortness of breath? *
A positive result from a COVID-19 test? *
Been in close contact with anyone who either tested positive for or developed symptoms for COVID-19? *
Traveled to any of these states, or any country designated by the CDC as a hotspot, within the last 14 days? *
TERMS & LIABILITY AGREEMENT. By clicking below, you affirm that you do not currently have a temperature of 100 degrees F or greater and have not: • to your knowledge been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or has had symptoms of COVID-19; • tested positive for COVID-19 in the past 14 days; • experienced any symptoms of COVID-19 in the past 14 days; and/or • travelled from a domestic or international location in the past 14 days that requires you to be under quarantine. Additionally, you agree and acknowledge that information regarding the COVID-19 virus and how it is transmitted continues to evolve, and protocols and guidance to reduce the spread of the virus are developing and changing on an ongoing basis. You further understand that the virus may be spread by people in close contact, including by infected people who have no symptoms, and that SHUFFLES is a place where, necessarily, members interact and share space, and that there is a risk that the COVID-19 virus could be transmitted. You expressly accept and assume these risks, whether or not caused by the fault or negligence of others. Check the box below to indicate your understanding of this statement. *
Never submit passwords through Google Forms.
This form was created inside of SHUFFLES. Report Abuse