1. Are either of the following statements true?
• I have tested positive for COVID-19 in the last 14 days.
• I have been tested because of COVID-19 symptoms and I am still waiting for results?

Yes     No

2. Do you live in a household with a person who has COVID-19 symptoms and: • Is waiting to take a COVID test; • is waiting on test results or; • has a confirmed COVID diagnosis

Yes     No

3. In the last 24 hours have you felt feverish or had a measured temperature greater than 100.4° F?

Yes     No

4. Over the past 24-hours, have you or anyone living in your household had any of the following symptoms that are not related to another condition (allergy or other medical diagnosis not related to COVID)? • Fever or chills • New cough • Shortness of breath • Stuffy nose • Sore throat • Muscle or body aches • New loss of taste or smell • Diarrhea or vomiting

Yes     No

5. In the past 10 days, have you come into close contact (within 6 feet for 15 minutes or more) with someone who has tested positive for COVID-19?

Yes     No

5. Are you currently under isolation or quarantine?

Yes     No