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2/5 Center School 2-5pm
Please complete this form for the day you will be getting tested.
Testing will be open from 2pm to 5pm
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* Indicates required question
Los últimos cuatro dígitos de tu número de seguridad social // What are the last 4 digits of your phone number?
*
Your answer
Segundo nombre // First Name
*
Your answer
Apellido(s) // Middle Initial
Your answer
Nombre // Last Name
*
Your answer
Fecha de nacimiento // Date of Birth
*
MM
/
DD
/
YYYY
Sexo asignado al nacer // Sex Assigned at Birth
*
Male
Female
Unknown
Other
Not applicable
Ambiguous
Intersex
Prefer Not to Say
Raza // Race
Native Hawaiian_Pacific Isl
White
Black
American Indian/Alaskan Native
Latino
Asian
Other
Clear selection
Ethnicity
Not Hispanic
Hispanic
Unknown
Clear selection
Dirección // Street Address?
*
Your answer
Ciudad // City
*
Your answer
Estado // State
*
Your answer
Código postal // Zip Code
*
Your answer
Número de teléfono // Telephone Number
*
Your answer
Correo electrónico // Email Address
*
Your answer
Cuál / cuáles de los siguientes síntomas experimentas // Which symptoms are you experiencing?
*
Fever over 100.4F
Felt Feverish
Chills
Muscle Aches
Headache
Runny Nose
Sore Throat
Cough
Fatigue
Diarrhea
Nausea or Vomiting
Shortness of Breath
Abdominal Pain
Loss of Taste or Smell
Increased Need for Oxygen
NONE
Required
Symptom Onset Date
MM
/
DD
/
YYYY
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