Coronavirus Screening Form
Email address *
Name *
Your answer
Contact phone # *
Your answer
Date of Birth *
MM
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DD
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YYYY
What is your relationship to Hunterdon Healthcare? *
What department do you work in? *
Your answer
Who is your Director? *
Your answer
What is your job title? *
Your answer
Where have you traveled to? *
Your answer
When did you return from your travel? *
MM
/
DD
/
YYYY
Anticipated return to work date? *
MM
/
DD
/
YYYY
Have you had potential exposure to a confirmed coronavirus case? *
If yes, where was exposure?
Your answer
If yes, when was exposure?
Your answer
Do you have a fever greater than 100.4? *
If yes, dates of fever
Your answer
If yes, temperature
Your answer
Do you have a cough? *
Do you have shortness of breath? *
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