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* 1. Have you had a temperature over 100.4 or chills or taken fever reducing medication in the last 48 hours? 

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* 2. Have you experienced any of the following symptoms in the last 48 hours?

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* 3. Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days?

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* 4. Have you traveled outside of the country or to one of the states that the PA department of health has indicated a need for quarantining during the past 14 days?

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* 5. Please provide your full name. 

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