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* 1. Name

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* 2. Temperature (F)

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* 3. Fever for you or anyone in your household (>100 degrees F) in past 72 hours

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* 4. Cough for you or anyone in your household in past 72 hours?

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* 5. Sore throat for you or anyone in your household in the past 72 hours?

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* 6. Shortness of breath for unexplained reasons for you or anyone in your household over the past 72 hours?

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* 7. Have you had close contact or cared for someone with COVID-19 in the past 3 days("close contact" is defined as within 6 feet of an infected individual for at least 15 minutes)?

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