Name *

First Name

Last Name

Have you or anyone in your household been diagnosed with COVID-19 in the last 14 days? *

Yes

No

Are you or anyone in your household exhibiting any COVID-19 symptoms, including fever, cough, or shortness of breath? *

Yes

No

Have you or anyone in your household had direct contact with anyone known to be infected with COVID-19 in the last 14 days? *

Yes

No

Have you or anyone in your household traveled outside the United States in the last 14 days? *

Yes

No

Have you or anyone in your household recently taking a COVID-19 test and the result are still pending? *

Yes

No