1. In the past 14 days, have you experienced any of the following symptoms?
- Fever or chills
- New loss of taste or smell
- Shortness of breath
- Sore throat
- Difficulty breathing
- Congestion or runny nose
- Nausea or vomiting
- Muscle or body aches
2. In the past 14 days, have you been in close contact (less than six feet) with anyone who is/was experiencing any of the above symptoms?
3. In the past 14 days, have you been in close contact (less than six feet) with anyone who has tested positive for COVID-19?
4. In the past 30 days have you tested positive for COVID-19 or have you been deemed presumptively positive for COVID-19 based on a healthcare provider’s assessment of your symptoms?
5. In the past 30 days have you or any member of your household been instructed to self-isolate/self-quarantine?
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