COVID Form

  • Date Format: MM slash DD slash YYYY
  • In the past 14 days, have you had close contact as defined as: a) Being within approximately 6 feet of a COVID-19 case for a prolonged period of time (greater than or equal to 10 minutes); OR b) Direct contact with infectious secretions from a patient with COVID-19. Infectious secretions may include sputum, serum, blood, and respiratory droplets (e.g., being coughed or sneezed on) with an individual diagnosed with COVID-19?
  • Within the last 10 days have you been diagnosed with COVID-19, had a test confirming you have the virus, or been advised to self-isolate or quarantine by your doctor or a public health official?
  • Have you had any one or more of the following symptoms today or within the past 24 hours, which is not new or not explained by another reason?: Fever, chills, cough, shortness of breath, sore throat, fatigue, headache, muscle/body aches, runny nose/congestion, new loss of taste or smell, or nausea, vomiting or diarrhea?