Coronavirus Self Health Screen
Sign in to Google to save your progress. Learn more
Email *
Last Name *
First Name *
Team *
Have you been to one of the following states during the last 14 days? This list is changing daily, please refer to this link for the most of to date information.  https://portal.ct.gov/Coronavirus/Travel *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Norwalk Public Schools. Report Abuse
Google Forms