BLO Individual Health Self-Assessment 2021
Please know that you are agreeing to inform BLO if you experience COVID-19 symptoms and/or test positive for it within one week after attending this event. If you do develop symptoms or test positive, you should contact Julia Harbutt at jharbutt@blo.org.

All information shared on this form will be kept confidential.
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What BLO event are you entering? *
Required
Name *
Phone Number *
What is the best phone number to reach you in case someone attending an event you are part of is later identified as having COVID-19? If this occurs, you will be contacted and it will be your responsibility to notify the others in your household.
(1) During the past 14 days you/ anyone in your household HAS NOT experienced any fever, cough, shortness of breath, or other symptoms of COVID-19. (2) In the past 14 days you/anyone in your household HAS NOT been in close contact† with healthcare providers caring for COVID patients, or those who have tested positive for COVID-19. (3) In the past 14 days you/anyone in your household HAS NOT been in close contact† with anyone known or suspected to have Coronavirus or COVID-19. (4) You are in compliance with the March 22, 2021 Commonwealth of Massachusetts Travel Advisory: https://www.mass.gov/info-details/covid-19-travel-advisory. *
† "close contact" means being present within six feet for 15 minutes or more over a 24 hour period.
Have you been diagnosed with COVID-19 and recovered in the past 90 days? *
Either answer will permit you to attend.
Did you receive your second vaccination for COVID-19 more than 14 days ago. *
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