Your Name (required)

Date (required)

Temperature (required)

PLEASE ANSWER THE FOLLOWING QUESTIONS: (required)

1. Any COVID- 19 symptoms in the past 14 days? YesNo
    

2. Any positive COVID- 19 diagnostic test in the past 14 days? YesNo
    

3. Any close contact with confirmed or suspected COVID -19 cases in the past 14 days? YesNo
    

4. Have you traveled within a state with significant community spread of COVID -19 for longer than 24 hours within the past 14 days? YesNo
    

*ANY TEMPERATURE OR ANSWERS OF YES MAY NOT ENTER THE FACILITY. FACE MASKS ARE REQUIRED AT ALL TIMES.

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