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* 1. Name

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* 2. Date

Date

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* 3. Which office are you planning on visiting?

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* 4. Are you visiting someone in the office?

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* 5. If yes, what is the name of the person you are visiting?

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* 6. Are you showing any signs of one or more of the following symptoms:

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* 7. Have you been diagnosed with COVID-19?

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* 8. Have you been in close proximity to, or live with, anyone who has been diagnosed with COVID-19 within the last 14 days?

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* 9. Have you traveled to a state currently listed on the Pennsylvania or New Jersey restricted travel list?  

https://www.health.pa.gov/topics/disease/coronavirus/Pages/Travelers.aspx

https://covid19.nj.gov/faqs/nj-information/travel-and-transportation/which-states-are-on-the-travel-advisory-list-are-there-travel-restrictions-to-or-from-new-jersey

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