Email address *

Name (first and last) *

Have you been diagnosed with COVID-19 at all? *

Have you had a cough, fever, sore throat, “tickly” throat, nausea, shortness of breath, headache, loss of smell, taste in the last 2 weeks? *

Has anyone in your germ pool been diagnosed with COVID-19? (GERM POOL is anyone you are in contact with WITHOUT a mask.) *

Have you been exposed to anyone who thinks that they might have COVID-19 in the last 2 weeks? (Inside or outside of your germ pool.) *

Are YOU ALWAYS wearing a mask when in contact with ANYONE outside of your germ pool? This includes grocery stores, places of worship, friend's houses, workplaces, and ALL PUBLIC SPACES. *

Are ALL OTHER PEOPLE IN YOUR GERM POOL always wearing a mask when in contact with ANYONE outside of your germ pool? This includes grocery stores, places of worship, friend's houses, workplaces, and ALL PUBLIC SPACES. *

Are you high risk? That means that you are over age 60, immune-compromised, and/or have heart and lung diseases. *

Anything to add or ask?