SAJ Covid Symptoms Questionnaire
This form is updated as of 1/27/2022
If you receive a score of 1 or higher please do not attend our in person programs at this time.
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Email *
Date *
List the first and last names of everyone for whom you are completing this form, that have the same answers (please resubmit separately for anyone who has a different answer, or needs their own email receipt). *
Have you previously sent in proof of vaccination to the SAJ office *
Required
Have you tested positive for COVID-19 in the past 10 days? *
1 point
Required
Do you *live in a household* with someone who has tested positive for Covid-19 in the past 10 days? *
1 point
Required
Have you been asked to quarantine, isolate, or remain home by a health authority in the past 10 days? *
1 point
Required
In the past 10 days have you had a fever over 100 degrees, sore throat, cough, headache, congestion or new shortness of breath? *
1 point
Required
By submitting this form you agree to wear your mask while inside the SAJ building.  
A copy of your responses will be emailed to the address you provided.
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