Your Name*

Your Email*

Have you traveled internationally or domestically within the past 14 days?*
yesno
If yes, please list your travel locations:

Have you knowingly been in direct contact with anyone who has traveled domestically or internationally in the last 14 days?*
yesno
If yes, please list travel locations:

Have you been in direct contact with anyone who has COVID-19 or is currently unwell or has a fever?*
yesno

Do you have any of the following symptoms? (check any that apply)*
A fever (100.4°F or higher) or a sense of having a fever?A cough that you cannot attribute to another health condition?Any shortness of breath or difficulty breathing that you cannot attribute to another health condition?Any chills that you cannot attribute to another health condition?Any headaches that you cannot contribute to another health condition?A sore throat that you cannot attribute to another health condition?Muscles aches (myalgia) that you cannot attribute to another health condition?A new loss of taste and smell?None of the above