Coronavirus Self Declaration Form
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name
First Name
Last Name
Email
example@example.com
Have you travelled abroad recently?
Yes
No
Name of the area(s) visited
Country, State, City
Dates of travel
Arrival and return dates for each area
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
Yes
No
Your relationship with the people and your last contact date with them
Please state whether you've experienced/are experiencing the following
Rows
Yes
No
Fever
1
2
Cough
3
4
Shortness of Breath
5
6
Persistent Pain in the Chest
7
8
I acknowledge that the information I've given is accurate and complete.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: