1. Have you been within approximately 6 feet (2 meters) of a person with COVID-19 for a prolonged period of time?

YESNO

2. Do you have a cough?

YESNO

3. Do you have any of the following new respiratory symptoms? Fever, sore throat, cough, shortness of breath?

YESNO

4. Have you recently lost your sense of smell or taste?

YESNO

5. Do you have any GI symptoms? Diarrhea? Nausea?

YESNO

6. Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?

YESNO

7. Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?

YESNO

8. Have you traveled outside the United States in the past 14 days?

YESNO

9. Have you traveled within the United States by air, bus, or train within the past 14 days?

YESNO