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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. Have you been fully vaccinated for COVID 19 (as defined by the CDC)?

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

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

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

T