COVID SCREENING

Welcome to your COVID SCREENING

NAME
PHONE
EMAIL
COMPANY
Are you currently experiencing, or have you experienced in the past 10 days, any of the following symptoms?Fever, Cough, Shortness of breath or difficulty breathing, Sore throat, New loss of taste or smell, Chills, Head ormuscle aches, Nausea, Diarrhea or vomiting

In the past 14 days, have been in close proximity to anyone who was experiencing any of the above symptomsor has experienced any of the above symptoms within two days from your close contact?

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

If you answered yes to number 2 and/ or 3, are you fully vaccinated?

 You are considered fully vaccinated 2 weeks after your seconds dose in a 2 dose series, such as Moderna of Pfizer or 2 weeks after a single dose vaccine such as Johnson and Johnson’s Jansen vaccine. 

Have you been tested for COVID-19 and are waiting to receive test results?

In the past 10 days, have you tested positive for COVID-19, or are you presumptively positive for COVID-19based on your health care provider’s assessment of your symptoms?

Have you been directed or told by the local health department, your employer or your healthcare provider toself-isolate or self-quarantine?