2. Name*
4. Facility*
6. Have you experienced any of the symptoms listed to the right in the past 48 hours?*

   1. Yes
   2. No
7. • Fever or chills
   • Cough
   • Shortness or 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
9. Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?

   1. Yes
   2. No
11. Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

    1. Yes
    2. No
13. Are you currently waiting on the results of a COVID-19 test?

    1. Yes
    2. No
15. Did you answer NO to ALL questions?*

    1. Yes
    2. No

    Access APPROVED. Please show this to security at the facility entrance. Thank you for helping us protect you and others during this time.
16. Did you answer YES to ANY questions?*

    1. Yes
    2. No

    Access to CDC facilities NOT APPROVED. Please see page 2 for further instructions. Thank you for helping us protect you and others during this time.
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19. Email address

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