Mandatory COVID-19 Screening
Please fill out this quick survey prior to your visit to help everyone stay safe and healthy!
Your name: *
2. Do you have any of the following signs or symptoms? *
Required
3. Have you travelled or have had close contact with anyone who has travelled in the past 14 days? * *
4. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19? * *
5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures when you had close contact with a suspected or confirmed case of COVID-19?
Clear selection
If you have answered "yes" to questions 1, 3, or have checked off signs or symptoms, you may need to reschedule your appointment. If you have answered "yes" to question 4 but "yes" to question 5, you may proceed with your appointment.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy