HHREC COVID-19 Visitor Questionnaire

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* 1. Name:

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* 2. Have you traveled Internationally within the past 14 days?

Yes

No

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* 3. Have you had close contact with or cared for someone diagnosed with COVID-19 in the past 14 days?

Yes

No

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* 4. Have you experienced any flu like symptoms within the last 14 days?

Yes

No