COVID-19 Screening Form

First Name *

Last Name *

Date *

Did you receive your final (or second) vaccination dose more than 14 days ago? *
YesNo

Do you have any of the following symptoms? *
Fever or chills?New onset cough or worsening chronic cough?Shortness of breath?Decrease or loss of sense of taste or smell?If adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)?If child <18 years of age: nausea/ vomiting, diarrhea?None of the above

Do you have a concern for a potential COVID-19 infection (e.g. is there an outbreak in the facility where you live, are you awaiting COVID-19 test results, etc)? *
YesNo

Have you tested positive for COVID-19 in the past 10 days or have they been told they should be isolating? *
YesNo