COVID-19 Symptom Self-Attestation Form

Lets an individual self-declare whether they have symptoms, a recent positive result, or contact with a confirmed COVID-19 case.

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Full Name

Nombre

Apellido

Email Address

Phone Number

Date of Birth

Have you experienced any of the following symptoms in the past 14 days? Check all that apply.

Fever Cough Shortness of breath Sore throat Loss of taste or smell Fatigue None

Have you tested positive for COVID-19 in the past 14 days?

Yes No

Have you been in close contact with someone who has tested positive for COVID-19 in the past 14 days?

Yes No

Are you currently under quarantine or isolation orders?

Yes No

Provide any additional information or comments about your symptoms or potential exposure.

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