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* 1. Name

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* 2. Have you had any of the following symptoms in the last 14 days, that is new or worsening or that you cannot attribute to another health condition?

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* 3. Have you tested positive for COVID-19 in the past 14 days, or waiting for results?

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* 4. Have you had close contact with someone who tested positive for COVID-19 in the past 14 days?

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* 5. Have you had contact with someone suspected of having COVID-19 in the past 14 days?

T