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* 1. Participant's Name:

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* 2. Have you or the participant had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt "feverish" or had a temperature that is elevated for you/100.0F or greater?

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* 3. Do you or the participant have any of the following symptoms (cough, shortness of breath, sore throat, nasal congestion, runny nose, body aches, loss of taste and/or smell, diarrhea, nausea, vomiting, fever/chills/sweats?

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* 4. Have you or the participant traveled internationally or outside of state in the last 14 days? Or, have you had any close contact in the last 14 days with someone with a diagnosis of COVID-19?

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* 5. I understand that the participant and I are expected to wear a face covering at all time (unless medical exception).

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