COVID-19 Screening Questionaire
Staff
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First Name *
Last Name *
In the past 14 days, have you had known close contact with any person with a lab confirmed case of COVID-19? *
Do you have any of the following symptoms that are not normal for you?                                                                  1. Cough 2. Shortness of Breath or difficulty breathing 3. Loss of taste or smell 4. Difficulty breathing or Shortness of breath 5. Headache 6. Chills 7. Sore throat 8. Shaking or exaggerated shivering  9. Significant muscle pain or ache 10. Diarrhea                                                                                                                                                                                                                                                                                                                                           *
Do you feel feverish or have a measured temperature greater than or equal to 100.4 degrees F ? *
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