1. Are you experiencing any of the below? Select all that apply.

  Sore throat
  Cough
  Fatigue
  Loss of smell or taste or appetite
  Shortness of breath or chest pains
  Fever or feeling of chills
  None

2. Were you exposed to anyone that was confirmed as COVID-19 positive in the last 14 days?

  Yes
  No

3. In the past 14 days have you visited or worked in a health care facility where COVID-19 has been reported?

  Yes
  No

Submit