COVID-19 Screening Form

Name of Attendee*

First Name Middle Initial Last Name

Within the last 15 days, have you or has anyone in your household:

Tested positive for COVID-19?*

Been exposed to COVID-19?*

Encountered anyone with flu-like symptoms?*

Encountered anyone who has tested positive for COVID-19?*

Traveled internationally?*

Traveled by airplane domestically within the United States?*

Traveled on a cruise ship?*

Had a fever (100.3 degrees Fahrenheit or above)?*

Had flu-like symptoms?*

Had a cough?*

Had a sore throat?*

Had shortness of breath?*

Had loss of smell?*

Had loss of taste?*

Service Date*

By checking the below box*

I certify that the statements set forth in this instrument are true and correct.

Name

This field is for validation purposes and should be left unchanged.