COVID-19 SCREENING QUESTIONNAIRE

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and us.

Name

Are you currently experiencing, or have you experienced in the past 14 days, any of the COVID19 symptoms? (Please take your temperature before you answer this question.)

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the COVID symptoms or has experienced any of the above symptoms since your contact?

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

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

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?

In the past 14 days, have you been on a commercial flight or traveled outside of the United States?

In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?

Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation.

COVID-19 SCREENING QUESTIONNAIRE

Thanks for submitting!