Have you traveled internationally in the last 4 weeks?*

What country did you travel to?*

Have you traveled out of state in the last 4 weeks?*

What state did you travel to?*

Have you been in close contact with persons who have traveled internationally in the last 4 weeks?*

What country did the person travel to?*

Have YOU or any person you have been in close contact with experienced the following within the last 2 weeks?*

Have you been tested for COVID-19 in the past 2 weeks?*

Please specify results:*

Signature

Acknowledgement:*

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Name:*

Date:*

COVID-19 Screening