Health Screening Questionnaire

First Name: *

Last Name: *

Email Address: *

Phone number: *

Event Date: * +

1. Within the last 14 Days, have you had close contact (i.e contact within six feet for more than a few minutes) with any person known to have tested positive for COVID-19? *

Yes

No

2. Do you have any symptoms of COVID-19 (e.g. cough, shortness of breath/difficulty breathing OR two or more of the following symptoms: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of sense of taste or smell) *

Yes

No

3. Have you or anyone in your home tested positive for COVID-19 within the past 14 days? *

Yes

No

4. Have you or anyone in your home been tested for COVID-19 due to having COVID-19 symptoms or due to having had close contact with someone who tested positive? *

Yes

No

5. Are you or anyone in your home in active quarantine or isolation status? *

Yes

No