Covid Screening Form

Name:

Please fill out this field.

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?

Yes

Have you had a fever in the last 24 hours of 100°F or above?

Yes

Have you been in contact with anyone in the last 10 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes

Please write your full name below for signature

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Enter today's date

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Sent on May 22nd, 2022