Name* First Last Do you have a temperature of 100 degrees or higher?* Yes No Have you or a member of your household had a temperature of 100 degrees or higher within the last 72 hours?* Yes No Do you or a member of your household have symptoms of Coronavirus such as fever, coughing, sore throat, new/recent loss of taste, smell, or shortness of breath* Yes No Have you been exposed to someone with a confirmed case of COVID-19 within the last 14 days?* Yes No Have you traveled anywhere by plane in the last 10 days without being fully vaccinated or having previously recovered from COVID?* Yes No
