Department of Transportation COVID Screening Questionnaire Form
Complete the Department of Transportation COVID Screening Questionnaire Form to help ensure the safety of all staff and visitors. Please answer each question accurately.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Screening
*
-
Month
-
Day
Year
Date
Have you experienced any of the following symptoms in the past 48 hours?
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Loss of taste or smell
None of the above
Have you tested positive for COVID-19 in the past 10 days?
*
Yes
No
Have you been in close contact with anyone who has tested positive for COVID-19 in the past 10 days?
*
Yes
No
Not sure
Have you traveled outside your state or country in the past 14 days?
*
Yes
No
What is your current temperature (if known)?
Have you received a COVID-19 vaccination?
*
Yes
No
Prefer not to say
Submit Screening
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