Name *

First Name

Last Name

Have you been in contact with someone that has a confirmed or potential diagnosis of COVID-19 ? *

Yes

No

Have you had contact, without appropriate PPE in place, with someone that has a confirmed or potential diagnosis of COVID-19 in the last 14 Days? *

Yes

No

Have you traveled outside the state of Pennsylvania, for more than 24 hours, except for work or school? *

Yes

No

Do you now, or have you had a fever of 100.4 or higher in the past 48 hours? *

Yes

No

Do you, or have you had, 'chills' within the past 48 hours? *

Yes

No

Do you have a cough? *

Yes

No

Do you have a sore throat? *

Yes

No

Do you have shortness of breath, or difficulty breathing? *

Yes

No

Do you have muscle pain or aches? *

Yes

No

Do you have a new loss of taste or smell? *

Yes

No

Within the past 24 hours, have you experienced symptoms related to COVID-19? (Symptoms include: fever of 100.4 or higher, cough, shortness of breath, chills, muscle pain, new lost of taste or smell). *

Yes

No

I attest that the information I have documented in this wellness questionnaire is truthful to the best of my knowledge. *

Yes

No