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Health Survey - HIPAA compliant
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Name
*
Your answer
HAVE YOU:
(a) knowingly been in close contact in the past 14 days with anyone who has tested positive forCOVID-19 or who has or had symptoms of COVID-19;
*
Yes
No
(b) tested positive for COVID-19 through a diagnostic test in the past 14 days;
*
Yes
No
(c) experienced any symptoms of COVID-19 in the past 14 days; and
*
Yes
No
(d) traveled within a state with significant community spread of COVID-19 for longer than 24hours within the past 14 days.
*
Yes
No
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