COVID-19 Screening Form

Name(*)

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Affiliation: (Company)(*)

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Do you want a copy of this sent to you?(*)

Yes

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Date(*)

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Do you have or have had the following symptoms in the last five days (check all that apply)?(*)

Sore throat

Dry cough

Runny nose

Headache

Fever

Labored breathing

Rash on feet

None

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Have you been exposed to anyone that has shown these symptoms in the last 14 days?(*)

Yes

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Have you been in another country in the last 30 days?(*)

Yes

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Have you been in contact with an individual or individuals that have been in another country in the last 30 days?(*)

Yes

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The following above responses have been answered truthfully to the best of my knowledge?(*)

Yes

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Signature(*)

Sign Above

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