COVID Questionnaire

First Name

Last Name:

Email Address

1) Have you traveled out of state in the past month?

If “yes” where did you travel and when?

2) Have you been diagnosed with COVID-19 in the past two weeks?

If “yes” when?

3) Have you had any COVID-19 related symptoms in the last 72 hours?

If “yes” when?

4) Have you been exposed to anyone who has been diagnosed with, suspected to have, or may be experiencing symptoms of COVID-19 in the past 14 days?