Name *

First Name

Last Name

1. Are you or anyone in your household required to self-isolate due to symptoms and/or a positive test result of COVID-19? *

YES

NO

2. In the last 48 hours, have you experienced a cough (new or worsening)? *

YES

NO

3. In the last 48 hours, have you experienced two or more of the following symptoms? *

Fever (i.e., chills/sweats)

Headache

Runny nose or nasal congestion

Sore throat

Shortness of breath or difficulty breathing

Nausea, diarrhea or vomiting

Not applicable