Please note that masks and social distancing are required for all staff and visitors in our building. Thank you for helping to keep our community safe! Name * First Name Last Name Email * Phone * (###) ### #### 1. Have you experienced any of the following symptoms in the past 48 hours: * Fever or chills, cough, shortness of breath / difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea YES NO 2. Have you been in close physical contact in the last 14 days with anyone who is known to have laboratory-confirmed COVID-19? OR anyone who has any symptoms consistent with COVID-19? * Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection). YES NO 3. Are you currently waiting on the results of a COVID-19 test? * YES NO 4. Have you traveled in the past 10 days? * Travel is defined as any trip that is overnight AND on public transportation (plane, train, bus, Uber, Lyft, cab, etc.) OR any trip that is overnight AND with people who are not in your household. YES NO 5. Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19? * YES NO 6. Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? * To be considered fully vaccinated, you must be 2+ weeks following receipt of the second dose in a 2-dose series or +2 weeks following receipt of one dose of a single-dose vaccine. YES NO PREFER NOT TO ANSWER I certify that my responses are true and correct * Checking this box certifies my responses Date * MM DD YYYY Thank you!
