Name *

First Name

Last Name

Date *

MM

DD

YYYY

Are you currently experiencing one or more Covid like symptoms that are new or worsening? *

Symptoms should not be chronic or related to other known causes or conditions.

Yes

No

Has a doctor, healthcare provider, or public health unit told you that you should be isolating (staying at home)? *

Either due to travel or contact tracing

Yes

No

Have you been in close contact with a person who has flu like symptoms and is in isolation? *

If fully vaccinated, select "NO"

Yes

No

Has someone you live with tested positive for Covid-19 in the past 14 days? *

Yes

No

Is anyone you live with currently experiencing any new Covid-19 symptoms and/or waiting for test results after experiencing symptoms? *

If you are fully vaccinated, select "NO". If the individual experiencing symptoms received a COVID-19 Vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select "NO"

Yes

No

I attest that the above is true to my knowledge and I take full responsibility to inform the owner if I develop any of the above symptoms during my time or come into contact with anyone testing positive for Covid-19 *

Yes

No