Health Grounds Application Checklist Form
Complete this checklist to submit a health grounds application. Use the same title consistently throughout the form.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method (select one)
Email
Phone
Text Message
Health Grounds Checklist
Health condition or symptom confirmation
*
Fever
Persistent cough
Shortness of breath
Fatigue
Loss of taste or smell
Other
Recent exposure or travel factors
Close contact with a sick person
Recent travel to a higher-risk area
Attended a large gathering
Shared living or caregiving environment
None of the above
Other
Eligibility self-attestation checklist
*
Information provided is accurate and complete
I am submitting this application for my own situation
I understand additional verification may be requested
I can provide supporting details if needed
Application readiness checklist
*
Completed all required fields in the form
Reviewed the supporting details section
Included any available relevant dates
Acknowledged all checklist items above
Supporting Details
Supporting Documentation (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Application Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Should be Empty: