JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Covid-19 Health Screening Log
Crosswinds Aviation COVID-19 Health Screening Log
Sign in to Google
to save your progress.
Learn more
* Required
Email
*
Your email
First and Last Name
*
Your answer
Body temperature at or above 100.4 degrees F?
*
Yes
No
Have a cough?
*
Yes
No
Have shortness of breath?
*
Yes
No
Have a Sore Throat?
*
Yes
No
Have Diarrhea?
*
Yes
No
Have Chills
*
Yes
No
Have New Loss of Taste or Smell?
*
Yes
No
In the Last 14 days have you knowingly had close contact with someone with a positive diagnosis of Covid-19?
*
Yes
No
In the last 14 days have you traveled via airplane internationally?
*
Yes
No
Agreement to Release of Liability
By submitting this form, you are agreeing to MIDWEST AIR LLC D/B/A CROSSWINDS AVIATION – RELEASE OF LIABILITY AND INDEMNITY AGREEMENT found here:
https://www.crosswindsaviation.com/release/
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Crosswinds Aviation.
Report Abuse
Forms
