Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

New Symptoms (Not Otherwise Explained): *

-Temperature Over 100.4°F -Chills -Cough -Shortness of Breath -Loss of Taste or Smell -Muscle Aches

Yes

No

Over the past 14 days, have you: *

Received a positive COVID-19 test?

Yes

No

Over the past 14 days, have you: *

Been told to quarantine due to exposure to COVID-19?

Yes

No

Travel: *

Have you traveled to any restricted states listed on the NYS Travel Advisory website (https://coronavirus.health.ny.gov/covid-19-travel-advisory) in the past 14 days?

Yes

No

I attest all of the information is true. *

Have you received a COVID-19 vaccine? *

Yes

No