Facilities COVID-19 Screening

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Email *

What is your name? *

Your company? *

Have you experienced any of the following symptoms in the past 48 hours: *

fever or chills

cough

shortness of breath or difficulty breathing

fatigue

muscle or body aches

headache

new loss of taste or smell

sore throat

congestion or runny nose

nausea or vomiting

diarrhea

None of the above

Required

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: *

Anyone who is known to have laboratory-confirmed COVID-19?

Anyone who has any symptoms consistent with COVID-19?

None of the above

Required

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? *

YES

Do you certify the above answers above to be true? *

YES

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