Health Screener

First Name

Last Name

Have you experienced any symptoms of COVID-19 in the past 14 days?
yesno

Have you tested positive for COVID-19 through a diagnostic test in the past 14 days?
yesno

Have you knowingly been in close contact with someone who has tested positive for COVID-19, OR who has or had symptoms of COVID-19 in the past 14 days?
yesno

Have you traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 days?
yesno

I agree that all information is accurate to the best of my knowledge.

Please leave this field empty.