Name* First Last Email* Do you have a temperature of 100 degrees or higher?*YesNoHave you or a member of your household had a temperature of 100 degrees or higher within the last 72 hours?*YesNoDo you or a member of your household have symptoms of Coronavirus such as fever, coughing, shortness of breath?*YesNoHave you been exposed to someone with a confirmed case of COVID-19 within the last 14 days?*YesNoHave you traveled outside the state of Ohio within the last 7 days?*YesNoWithin the last 14 days, have you or a member of your household traveled to a high-risk area for Coronavirus such as New York City, New Orleans, Chicago, Detroit, Miami, Los Angeles, Seattle?*YesNo
