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* 1. First Name:

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* 2. Last Name:

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* 3. Phone Number

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* 4. Program

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* 5. Within the last 14 days, have you tested positive for COVID-19 or been diagnosed as COVID-19 positive by a health care provider or have you been in close/direct contact with an individual who has been diagnosed as infected with or being screened or monitored for COVID-19 or has been advised to self-quarantine by a healthcare provider?

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* 6. Are you or anyone in your household currently experiencing any COVID-19 related major symptoms which include but are not limited to a cough, fever of 100.4°F, or shortness of breath/difficulty breathing or TWO or MORE of COVID-19 related other symptoms which include, but are not limited to, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell? This includes COVID-19 vaccine side effects.

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* 7. Are you feeling ill today?

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