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Grace COG Covid-19 Questionnaire
Please answer the questions below to confirm your current health status
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Email
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Your email
What is today's date?
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MM
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YYYY
Please write your full name below
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Your answer
Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath within the past 10 days?
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No
Yes, and I have received a negative result from a COVID-19 test since the onset of symptoms AND have not had symptoms for at least 24 hours.
Yes, and I am not in the category above
In the past 10 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab?
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Yes
No
To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone who tested positive for COVID-19 or who has or had symptoms of COVID-19?
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Yes
No
Are you considered fully vaccinated against Covid-19 by CDC guidelines? Please note that to be considered fully vaccinated by CDC, two weeks must have passed since you received the second dose in a two-dose series or since you received a single-dose vaccine.
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No, I am not considered fully vaccinated
Yes, I am considered fully vaccinated
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