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NYC Impact Health Screening Questionnaires
All Participant must completes the Health Screen Questionnaires at least one hour before arriving at the scheduled event.
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* Indicates required question
Full Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Have you experienced any of the following symptoms in the past 48 hours:
*
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
No
Required
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?
*
Yes
No
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
*
Yes
No
Are you currently waiting on the results of a COVID-19 test?
*
Yes
No
I hereby certified that
*
Above statements are true and correct to the best of my knowledge.
Required
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