COVID Questionnaire

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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 10 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?

Yes

No

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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, cough, fatigue, nausea, vomit, diarrhea, congestion, runny nose, muscle or body aches or new loss of taste or smell? This includes COVID-19 vaccine side effects.

Yes

No

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* 7. Are you feeling ill today?

Yes

No