Stars VB Covid-19 Screening
* Required
Name
*
Choose
12 Chloe
13 Bre
14 Gabby
15 Amalia
16 Emily
17 Bre
18 Gina
18 State Deb
18 State Gina
Name
*
Your answer
Temperature
*
Your answer
Symptoms
*
Do you have any or have had any of the following symptoms within the last 24 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
Required
Close Contact
*
Have you been in close contact with someone with COVID-19?
Yes
No
Exit
*
I will exit this screen from my phone after submitting
Yes
No
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
