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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 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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