Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Have you been sick within the past 15-30 days? (Coughing, Sneezing, Fever, Difficulty Breathing, Chest Pain or Headaches)
*
Yes
No
Are you an “Essential Worker” that continued to report to work? (Not working from home)
*
Yes
No
In the last 15 days, have you recently traveled to an area with a known spread of COVID19 or exposed to anyone diagnosed with or showing symptoms of COVID19 (work, family, church, doctors office, hospital, or large crowds)?
*
Yes
No
Have you been following the “Stay At Home” executive order for self quarantine/isolation and practicing social distancing? (Excludes essential activities like grocery trips or medical appts)
*
Yes
No
Submit
Should be Empty: