Covid 19 Questionnaire

CONFIDENTIAL INFORMATION

Use of the personal information is limited to the bounds of our Privacy Policy

Given Name:
Surname:
Email Address:
Q1. Are you experiencing ANY of the following: Fever, chills, acute upper respiratory infection (including cough, shortness of breath, loss of smell, taste), headache, muscle arches, stuffy nose, nausea, vomiting or diarrhea?---YesNo
Q2. Have you come into close contact with a confirmed case of COVID-19 in the past 14 days without using the recommended PPE?---YesNo
Q3. Have you been diagnosed with COVID-19 or are you waiting for COVID-19 test results?
---YesNo