Date of Event Attended *

MM

DD

YYYY

Date of Symptoms Onset

Best Estimate

MM

DD

YYYY

Symptoms - Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?

Please check all that apply

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

None

Have you been tested for COVID-19 within the like 14 days? *

Yes

No

Are you waiting to receive COVID-19 Test Results?

Yes

No

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?

Yes

No

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

I Agree