1. Have you experienced any of the following symptoms in the past 48 hours:

• fever or chills
• cough
• shortness of breath or difficulty breathing
• fatigue
• muscle or body aches
• headache
• new loss of taste or smell
• sore throat
• congestion or runny nose
• nausea or vomiting
• diarrhea

Yes

No

2. Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19? *

Yes

No

3. Have you been in close physical contact in the last 14 days with:
Anyone who is known to have laboratory-confirmed COVID-19? OR
Anyone who has any symptoms consistent with COVID-19?
(Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection). *

Yes

No

4. Are you currently waiting on the results of a COVID-19 test?
IMPORTANT: ANSWER “NO” IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST *

Yes

No

5. Have you traveled in the past 10 days? Travel is defined as any trip that is overnight AND on public transportation (plane, train, bus, Uber, Lyft, cab, etc.) OR any trip that is overnight AND with people who are not in your household. *

Yes

No