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Complete this survey 24hours or less prior to attending an event with Leadership Baltimore County. Please read each question carefully and answer honestly.

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* 1. Name (First and Last)

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* 2. Date

Date

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* 3. Event Name

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* 4. Have you experienced any of the following symptoms in the past 48 hours:  
  • fever or chills  
  • cough  
  • shortness of breath or difficulty breathing  
  • fatigue • muscle or body aches  
  • headache  
  • new loss of taste or smell  
  • sore throat  
  • congestion or runny nose  
  • nausea or vomiting 
  • diarrhea

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* 5. Are you unvaccinated and have been in close physical contact (6 feet or closer for at least 15 minutes) within the past 10 days with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19? (Note: If you have been exposed and your are vaccinated, you may attend but must wear a mask for the duration of your attendance.)

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* 6. Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

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* 7. Are you currently waiting on the results of a COVID-19 test?

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* 8. Signature (please type in your full name, this will serve as your digital signature)

If you answered “no” to all questions, you may attend the event. 

If you answered “yes” to any question, you may not attend the event. Visit the CDC website for further information on when to get tested, what to do if you are sick, and other guidance: https://www.cdc.gov/coronavirus/2019-nCoV/. 
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