In the past 10 days have you experienced any of the following new or worsening symptoms?
• Fever, fatigue, shortness of breath, or difficulty breathing
• Sinus congestion, runny nose, sore throat, muscle or body aches
• Loss of taste or smell, headache, loss of appetite or gastrointestinal discomfort
• Persistent cough
Yes No

In the past 14 days, have you been told you have COVID-19 or asked to quarantine? Yes No

If you are not fully vaccinated with an approved COVID-19 vaccine, in the past 14 days have you had close contact or high risk exposure to someone with an active or suspected case of COVID-19? Yes No

In the past 10 days have you been asked to get a COVID-19 test and are still waiting for the results or have received an inconclusive result? Yes No