Health Questionnaire

This form is to log visitor interactions, per facility guidelines, and to notify public health authorities and inform emergency operations if needed.

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* 1. Please enter today's date and current time.

Date
Time

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* 2. What was the purpose of your visit today? Please click all that apply.

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* 3.
  • I do not have a fever, or have had one within 14 days.
  • I do not have a cough.
  • I do not have a sore throat.
  • I do not have other symptoms associated with COVID-19 such as a fever, loss of taste or smell, gastrointestinal problems such as nausea, diarrhea or vomiting.
  • I have not been in close contact with a person diagnosed with COVID-19 in the past 14 days.
  • I have not been directed to self-isolate or quarantine by a health care provider or public health official.
  • I have not received a positive test result or diagnosis based on COVID-19 symptoms.
  • I have not recently traveled to any of the CDC’s designated affected countries/areas within the last 14 days.
  • I have practiced social distancing using CDC guidelines (staying a minimum of 6ft away from other people).
  • I do not share a residence with someone who has been diagnosed or is presently showing symptoms of COVID-19.
  • I do not share a residence with someone who has been in contact with anyone with COVID-19.

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* 4. If you do not agree with any of the above statements, we ask you to come back once you have tested negative for COVID-19 as well as not showing any other symptoms of illness.

Please acknowledge your understanding of this form by filling out the information below.

Please show your answer to a staff member once you click "done".

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