COVID19 Form
First
Last
(e.g. XXX-XXX-XXXX)
Have you or anyone in your household had any of the following symptoms in the last 14 days?
Have you ever been tested for COVID-19? *
Have you or anyone in your household been exposed to COVID-19 in the past 14 days? *
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other healthcare facility in the past 14 days? *
Have you or anyone in your household traveled on an airplane or cruise ship in the past 14 days? *