Name *

First Name

Last Name

Do you have a fever (temperature over 100.30F) without having taken any fever reducing medications? *

Yes

No

Are you experiencing any of these symptoms? *

Sore throat

New loss of smell or taste

Muscle aches

Congestion

Cough

Shortness of breath

Chills

Headache

Nausea/vomiting

Diarrhea

I am not experiencing any symptoms

Have you, or anyone you have been in close contact with, been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19? *

Yes

No

Have you been asked to self-isolate or quarantine by a medical professional or a local public health official? *

Yes

No