COVID Questionnaire – Formstack

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COVID-19 Screening Form

Name*

Are you a(n):*

Which site are you attending?*

Have you received a COVID vaccine?*

Have you received all the required Covid vaccines for that vendor?*

In the last 14 days, have you had a positive COVID-19 test? *

In the last 14 days, have you been in close contact with anyone who has tested positive?*

In the last 72 hours have you had close contact with someone diagnosed with COVID‐19?*

In the last 72 hours have you had close contact with who is under investigation or in quarantine for possible COVID‐19 infection? Close contact is defined as any individual who was within 6 feet of an infected person for at least 15 minutes.*

In the last three days have you had any of the following symptoms (check all that apply):*

In the last 24 hours, have you taken fever-reducing or other symptom-altering medicines due to COVID or COVID like symptoms (e.g. ibuprofen, Tylenol, or cough suppressants)?*

Do you currently have COVID-19, or are you caring for someone who has COVID-19?*

By checking below I certify that the responses provided above are true and accurate to the best of my knowledge and participation in this event is voluntary.*


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