COVID-19 Screening - Blue Dolphin Pool Question Title * 1. Name(s) of Individual(s) entering the Facility? Question Title * 2. Date/Time of Entry ? Date / Time Date Time AM/PM - AM PM Question Title * 3. Do you currently have one or more of the COVID-19 symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions. Fever / Chills New cough or a cough that has worsened Difficulty breathing Shortness of breath Sore throat A runny or congested nose Unusual level of fatigue Unusual headache Nausea, vomiting, diarrhea, or loss of appetite None of the above Question Title * 4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?This can be because of an outbreak or contact tracing. Yes No Question Title * 5. Do you live with someone who has been told by a doctor, health care provider, or public health unit that they should currently be isolating? If you are fullyvaccinated**, select “No.”If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” Yes No Done