Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?
  • Fever (100.4 or greater)
  • Chills
  • New cough
  • Shortness of breath
  • Sore throat
  • Muscle aches
  • New headache
  • Loss of taste or smell
  • Diarrhea, nausea, or vomiting
  • Have you been exposed to, or in the proximity of anyone, that is known to have tested positive for COVID-19, or anyone who is waiting on COVID-19 results?


The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.