COVID19 Online Questionnaire Form

Your Name

Your Email

Phone

Do you have any of the following?
CoughFever or chillsShortness of breath or difficulty breathingMuscle or body achesSore throatNew loss of taste or smellDiarrheaHeadacheNausea or vomitingNew fatigueCongestionrunny noseNone of the above

Have you cared for, or had close contact with, someone diagnosed with COVID-19 or been notified that you may have been exposed to it?
YesNo

In the last two weeks, have stayed within the states of Pennsylvania, New Jersey, and Maryland?
YesNo

Have you answered the questions above to the best of your knowledge?
YesNo

By clicking submit, I certify that I have answered all questions truthfully and to the best of my ability.

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