Health Assessment

TEMPERATURE TAKEN REQUIRED Yes No Please fill out this field.

Do you currently have (or have had in the last 10 days) one or more of these new or worsening symptoms:

Do you have temperature greater than or equal to 100 degrees F? REQUIRED Yes No Please fill out this field.

Loss of smell or taste? REQUIRED Yes No Please fill out this field.

Muscle Aches? REQUIRED Yes No Please fill out this field.

Sore Throat? REQUIRED Yes No Please fill out this field.

Cough? REQUIRED Yes No Please fill out this field.

Shortness of Breath? REQUIRED Yes No Please fill out this field.

Chills? REQUIRED Yes No Please fill out this field.

Nausea/vomiting, diarrhea, loss of appetite? REQUIRED Yes No Please fill out this field.

Have you been asked to self-isolate or quarantine by a medical professional or local health department? REQUIRED Yes No Please fill out this field.

Are you FULLY vaccinated (to be FULLY vaccinated it must be 2 weeks after the receipt of the second dose in a 2-dose series OR 2 weeks after the receipt of a single dose vaccine)? REQUIRED Yes No Please fill out this field.

If you answered "YES" to the vaccination question AND "NO" to the other questions above, please skip to the certification step below.

If you answered "NO" to the vaccination question please answer the remaining questions below and then complete the certification step.

In the past 10 days have you tested positive for COVID-19 OR are you waiting for a COVID-19 test result? Yes No

Have you been designated a contact of a person who tested positive for COVID-19 by a local health department? Yes No

In the last 14 days, have you traveled internationally? Yes No

CERTIFICATION STEP:
I certify that my responses above are true and correct.

Staff Member/Visitor Name: REQUIRED Please fill out this field. Please enter valid data.

Date: REQUIRED Please fill out this field. Please enter valid data.