Screening Questions

Your Name

First

Last

Email address*

In the past 14 days, have you or anyone in your household been potentially exposed to COVID-19?*

Yes

No

Unknown

Have you or anyone in your household traveled on an airplane or to an area with higher risk COVID-19 activity within the last 14 days?*

Yes

No

Unknown

Do you or anyone in your household have a cough or shortness of breath or difficulty breathing; or at least two of the following symptoms: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat or new loss of taste or smell; and the symptoms could be related to potential exposure to COVID-19?*

Yes

No

Unknown

Have you or anyone in your household tested positive for COVID-19 in the past 14 days?*

Yes

No

Unknown

This field should be left blank

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