Alternatives Health Check-In: Members of the Public

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* 1. Name *

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* 2. Email *

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* 3. Why are you completing this survey?

I have an appointment for a new account or a new loan

I have a Tax Program appointment

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* 4. Do you have a fever – temperature rating of more than 100.4 degrees *

Yes

No

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* 5. If I am taking my temperature rating at home I attest that I have a reliable thermometer *

Yes

No

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* 6. Have you had any COVID-19 symptoms in the past 14 days? (i.e. fever, cough, shortness of breath, chills, sore throat, new loss of taste or smell, muscle pain) *

Yes

No

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* 7. Have you tested positive for COVID-19 in the past 14 days? *

Yes

No

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* 8. Have you had close contact with a confirmed or suspected COVID-19 case in the past 14 days? *

Yes

No

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* 9. Have you traveled out of the United States in the last 14 days? *

Yes

No

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* 10. If yes, what country have you traveled to?