In accordance with health and safety measures, Intercept Pharmaceuticals, Inc., (hereinafter Intercept) is screening for COVID-19 exposure and symptoms of all of our guests before they attend an offsite Intercept sponsored speaker programs. 
*NOTE: In addition to completing the online survey, you will be asked to complete a COVID-19 screening form onsite prior to the event. As a condition of your participation, you will be asked to execute a liability waiver onsite []*

Question Title

* 1. By signing below, you are attesting to the following:

You are currently symptom-free and have had no known exposure to COVID-19, meaning:

·       You have not, in the last 14 days, had any close contact (i.e., within 6 feet for 10 minutes or more) with anyone who is either confirmed or suspected of being infected with COVID-19, including anyone who was experiencing or displaying any of the known symptoms of COVID-19 (which are listed below);

·       You have not tested positive for COVID-19 within the last 14 days; AND

·       In the last 14 days, including today, you have not experienced any of the following COVID-19 symptoms:

                 i.      Elevated temperature or fever of 100.4 F or higher,

                ii.      Cough, shortness of breath and/or difficulty breathing,

                iii.      New loss of smell and/or taste,

                iv.      Sore throat, congestion, or runny nose,

                 v.      Nausea, vomiting, or diarrhea, or,
                vi.      Fatigue, muscle aches, chills, shaking, or headaches.