COVID-19 Consent Form
First Name *
Last Name *
Have you had a fever in the last 7 days? *
Do you now, or have you recently had, a persistent dry cough? *
Do you have any other symptoms that may mean you have a COVID-19 infection? (loss of smell, unusual fatigue or shortness of breath) *
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *
Have you been told to stay home, self-isolate or self-quanrantine? *
Date: *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy