Date                      
                         
  Name                  
_________ _________ _________ _________ _________ _________ _________ _________ _________ _________
1. Do you have current symptoms of COVID-19, such as:  
a. a fever, Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___
b. a new or changed chronic cough, Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___
c. a sore throat that is not related to a known or preexisting condition Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___
d. a runny nose that is not related to a known or preexisting condition Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___
e. Nasal congestion that is not related to a known or preexisting condition Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___
f. Shortness of breath that is not related to a known or preexisting condition Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___
2. Have you traveled internationally within the last 14 days? Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___
3. Have you had unprotected close contact with individuals who have a confirmed or presumptive diagnosis of COVID-19 (e.e. individuals exposed without appropriate PPE in use)? Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___ Y___ N___