Highland Regiment COVID-19 screening
Please answer these questions truthfully and to the best of your ability.
Name *
Email address *
Phone number *
Have you experienced any of the following symptoms in the past 48 hours? *
Yes
No
Fever (temperature over 100°F) or chills
Cough
Shortness of breath
Fatigue
Muscle or body ache
Headache
A new loss of taste or smell
Sore throat
Congestion or runny nose (not related to allergies)
Nausea or vomiting
Diarrhea
Within the past 14 days, have you been in close physical contact with someone known to have laboratory-confirmed COVID-19, or anyone with symptoms consistent with COVID-19? *
"Close physical contact" is defined as being within 6 feet for a total of 15 minutes
Are you isolating or quarantining because you may have been exposed to a person with COVID-19, or are worried that you may be sick with COVID-19? *
Are you currently waiting on the results of a COVID-19 test? *
In the past 14 days, have you traveled outside of New Jersey and surrounding states? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy