MOMS MOPTO COVID-19 Pre-Screening Questionnaire

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Email *

Last Name of Student *

First Name of Student *

Are you experiencing any of the following symptoms? *

Fever over 100.4 degrees

Cough or shortness of breath

sore throat

Chills

Muscle Aches

Headache

New lost sense of taste or smell

abdominal pain, nausea, vomiting

diarrhea

none

Required

Have you had close contact with someone who is currently sick? *

Yes

Have you been diagnosed with COVID-19 in the past three weeks or have reason to believe you have COVID-19? *

Yes

If yes, what was the date of the positive COVID-19 test?

YYYY

Have you traveled or had close contact with anyone who has traveled outside of New Jersey in the last 14 days? As of July 21st, there are currently 31 states that require a 14-day quarantine after your arrival back to New Jersey. *

Yes

If yes, please fill the the states you visited.

If yes, please list the date of your return to New Jersey

YYYY

A copy of your responses will be emailed to the address you provided.

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