COVID-19 Symptoms Form

COVID-19 Symptoms Form
This form must be filled out everytime you volunteer for the Benson Hill Food Project Drive-Through.
You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come and volunteer.
If you experience any symptoms or answer “YES” to any of these questions, you must contact Monica Brown (425-221-5518) for next steps and finding a replacement.
1) Have you had any of the following symptoms in the last 24 hours?
Rows Yes No
Cough
Shortness of breath of difficulty breathing
OR at least TWO of the following symptoms in the last 24 hours:
Rows Yes No
Fever (usually 100.4 F or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
If you answered “Yes” to question one, please DO NOT come to volunteer. You should:
- Self-quarantine for at least 14 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
2) In the last 14 days have you:
Rows Yes No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise
If you answered “Yes” to any part of question two, please DO NOT come to volunteer. You should self quarantine for at least 14 days.
I certify to the best of my knowledge; this information is accurate.
Signature of Volunteer
Clear
Name
First NameLast Name
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	Yes	No
Fever (usually 100.4 F or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

Rows	Yes	No
Cough
Shortness of breath of difficulty breathing