*Name

*DOB

*Gender

*Address

*Phone

*Email

Ok to Text ?

Yes

No

*2. In the last 2 weeks, have you had contact (within 6 ft. of the person for a prolonged period of time or been coughed on) with someone who has been diagnosed with or presumed to have COVID-19?

Yes

No

*3. In the last 2 weeks, have you been in contact (within 6 ft. of the person for a prolonged period of time or been coughed on) with someone who is sick but has not been diagnosed with COVID-19?

Yes

No

NOTE: If you are a healthcare professional who believes you have been directly exposed while at work by a patient, you should consult your place of work for specific occupational health guidance about whether to stay home or continue working while waiting for your results. You should adhere to recommendations set forth by your employer or the Department of Health, as they may differ from the CDC's guidelines.

*4. In the last 2 weeks, have you had any of the following exposures? (Select all that apply)

International travel

Live in or have visited an area where there has been community spread of COVID-19*

None of these

*5. Do any of the following describe your work setting? (Select all that apply)

Healthcare Facility: I work in a clinic, hospital, nursing home, or senior care facility or other healthcare facility

First Responder: I am a first responder, such as an ambulance worker, law enforcement officer, or firefighter

None of the above

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