COVID-19 Information

Date:

Name

Phone:

Are you a staff member, volunteer, vendor, other:

Staff Member

Volunteer

Vendor

Other

In the last 14 days have you been in close contact with someone who had COVID-19 symptoms or tested positive? (Close contact meaning being within 6 feet of someone for more than 10 minutes.)

Yes

No

In the past 14 days have you experienced ANY of the following symptoms: fever (100F/37.8C or greater, cough, shortness of breath, difficulty breathing, sore throat, fatigue, new loss of taste or smell, chills, congestion, runny nose, headache, muscle or body aches, nausea, vomiting or diarrhea?

Yes

No

In the last 14 days have you traveled internationally or had contact with someone who traveled internationally?

Yes

No

What is your current temperature? (If greater than 100F or 37.8C, Contact LaKeesha Sowell)

I hereby certify that the responses provided above are true and accurate to the best of my knowledge. (Yes/No)

Yes

No

COVID-19 Screening