Date:

How do you experienced any of the following symptoms below:
Fevers or chillsShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaNone

Within the past 14 days have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?:
YesNo

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?:
YesNo

Are you currently waiting on the results of my COVID-19 test?:
YesNo

Did you get vaccinated against COVID-19?:
YesNo