Date

First Name Last Name Email Do you currently have any of the symptoms listed below or have had any of them for the last 14 days? - Optional Cough - Optional

Cough Yes No

Fever greater than 104 F - Optional

Fever greater than 104 F Yes No

Shortness of Breath - Optional

Shortness of Breath Yes No

Have you tested positive for COVID-19 in the last 14 days? - Optional

Have you tested positive for COVID-19 in the last 14 days? Yes No

Have you been in close contact with a confirmed or suspected COVID-19 case in the past 14 days? - Optional

Have you been in close contact with a confirmed or suspected COVID-19 case in the past 14 days? Yes No

Within the last 14 days, have you returned from a state in the NY, NJ, CT state travel advisory list? - Optional

Within the last 14 days, have you returned from a state in the NY, NJ, CT state travel advisory list? Yes No

Within the last 14 days, have you traveled internationally? - Optional

Within the last 14 days, have you traveled internationally? Yes No

I agree I have answered the questions on this form to the best of my knowledge

I agree I have answered the questions on this form to the best of my knowledge Yes