COVID-19 QUESTIONNAIRE

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to protect our members.

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* 1. Full Name

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* 2. Cell Phone Number

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* 3. Email

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* 4. Check below if you are currently experiencing , or have experienced any of the following symptoms in the last 14 days?

Fever (100.4F / 37.8C or greater)

Cough

Shortness of breath or difficult breathing

Sore throat

New loss of taste or smell

Chills

Head or muscle aches

Nausea, diarrhea, vomiting

None of the symptoms above

If you have/had more than one symptom above, please list them here:

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* 5. In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

Yes

No

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* 6. In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

Yes

No

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* 7. I hereby certify that the responses provided above are true and accurate to the best of my knowledge (type initials)