1.First and Last Name

*2.Are you currently experiencing, or have you experienced in the last 14 days, any of the following symptoms? Please check all that apply.(Required.)

Fever (100.4 F/ 37.8 C or greater)

Cough

Shortness of breathe or difficulty breathing

New loss of taste or smell

Chills

Head or muscle aches

Nausea, diarrhea, or vomiting 

None of the above

*3.In the past 14 days, have you been in close contact with anyone who has tested positive for COVID-19?(Required.)

Yes

No

Maybe

*4.In the past 14 days, have you tested positive for COVID-19?(Required.)

Yes

No