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* 1. What is your name and phone number?

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* 2. Choose an Activity

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* 3. In the past 14 days have you had close contact with a person confirmed to have COVID-19?

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* 4. Have you been confirmed positive for COVID-19?

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* 5. Have you been in close contact with any persons who have traveled and are also exhibiting acute respiratory illness symptoms?

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* 6. Today or in the past 24 hours have you had a cough or sore throat?

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* 7. Today or in the past 24 hours have you had shortness of breath or difficulty breathing?

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* 8. Today or in the past 24 hours have you had a Fever (> 100.4°F / 38°C) or felt feverish?

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* 9. Today or in the past 24 hours have you had chills or muscle pain?

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* 10. Today or in the past 24 hours have you had new loss of taste or smell?

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