1. Within the past 14 days, have you had (or do you have):


a. Bluish lips or face?

b. Sever and constant pain or pressure in the chest

c. Extreme difficulty breathing (such as gasping for air or being unable to talk without catching your breath)?

d. Severe and constant dizziness or lightheadedness?

e. New serious disorientation (acting/feeling confused)?

f. Unconsciousness or extreme difficulty waking up?

g. New or worsening slurred speech or difficulty speaking?

h. Seizures?

i. Signs of low blood pressure (too weak to stand, lightheadedness, feeling cold, or pale/clammy skin)?

j. Fever or chills?

k. Cough?

l. Shortness of breath or difficulty breathing (other than a pre-existing non-COVID diagnosis)?

m. Fatigue?

n. Muscle or body aches?

o. Headache?

p. New loss of taste or smell?

q. Sore throat?

r. Congestion or runny nose?

s. Nausea or vomiting?

t. Diarrhea?


  1. Traveled internationally?
  1. Been asked to quarantine, isolate or self-monitor by any medical provider, health agency or hospital?
  2. Been diagnosed with COVID-19, or had a positive COVID-19 test?
    a. If yes, have you been symptom free with no fever, without fever-reducing medicine, for 72 hours; and
     b. Has it been at least 10 days since the date your symptoms began or, if you were asymptomatic, 10 days since the date of your positive test?
  3. Been in close contact with someone who has been diagnosed with COVID-19?
     a. If yes, were you wearing Personal Protective Equipment (PPE)?