COVID-19 Screening Questionnaire

1. Are you experiencing any of these symptoms? (Check all that apply)

Fever, sweats, or chills

Difficulty breathing

Cough

Sore throat

Body aches

Vomiting

Diarrhea

Loss of smell

Loss of taste

None of the above

2. Do you live or have visited in the last 14 days an area where COVID-19 is widespread (e.g., NJ, NY)?

Yes

No

3. In the last 14 days, have you been exposed to others who are known to have COVID-19?

Yes

No

Don't know (e.g., shopping, work or other public places)

4. In the last 14 days, have you visited a hospital, nursing home, or health care facility?

Yes

No

Covid-19 Sign up form