Self Assessment Health Questionnaire

NO MEDICAL INFORMATION WILL BE STORED

Your name, phone number, and email are stored for at most a month for contract tracing, so that we may contact you should we discover any positive cases of COVID-19 in our building.

Name
Email
Phone
1. 
Do you have a fever or feeling feverish?

2. 

Have you been in close, physical contact (6 feet or closer for at least 15 minutes) with anyone who has tested positive for COVID-19 within the last 10 days?

3. 

COVID Test Results

4. 
Are you exhibiting any of the following symptoms:

Sore throat?
New cough (not related to any chronic conditions)?
New nasal congestion or runny nose (not related to allergies)?
Muscle aches?
New loss of smell?
New loss of taste?
Shortness of breath?

5. 
Please Enter Your Temperature As Checked By Our Staff

6. 

Do you attest to answering this Screening Survey honestly and accurately to how you are feeling at the current time?