-Covid Assesment Form

You are being asked to answer this questionnaire to determine whether you have or may have COVID-19 or may have been recently exposed. This is being done solely for the purpose of protecting your workplace from potential spread of the disease. Any response you provide, and/or any directive you receive to stay home, does not constitute a diagnosis of COVID-19, nor are we advising you whether you need to get tested or contact a physician. You can consult CDC and health department websites for guidance in that regard.

Name:

Email Address:

Are you presently experiencing any symptoms of COVID-19, including, but not limited to, a fever of 100.0 degrees F or greater, chills, a new cough, sore throat, a new-onset loss of taste or smell, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, congestion or runny nose, nausea, vomiting, or diarrhea, or have you experienced any such symptoms in the last five days?

No.
Yes, but I have received a negative result from an approved COVID-19 diagnostic test (including PCR, at-home, and antigen) since experiencing the symptoms, and I have not suffered any symptoms for at least 24 hours without using fever-reducing medications.
Yes, but those symptoms began more than five days ago and since they began, I received a positive COVID-19 diagnostic test (including PCR, at-home, and antigen). It has been at least five days since that positive test, and I have been fever-free for 24 hours without the use of fever-reducing medication and my other symptoms are improving.
Yes, but I do not meet the criteria in the categories above.

Have you received a positive COVID-19 diagnostic test (not an antibody test) in the past five days?

No.
Yes, but I have previously tested positive for COVID in a separate diagnostic test within the last 90 days, and it has been at least ten days since that test., and I otherwise meet the requirements in Question 1.
Yes, but I do not meet the criteria in the categories above.

Have you been in close contact – within six feet for at least a total of ten minutes over a 24-hour period – within the past five days with anyone who has been diagnosed with COVID-19 or has been suffering from COVID-19 symptoms?

No.
Yes, but I am fully vaccinated, in that it has been more than ten days since I received the second shot of the two-dose Pfizer or Modern vaccine, or fourteen days since I received the single shot of the Johnson and Johnson vaccine, or I have recovered from a diagnosed case of COVID-19 within the past 90 days.
Yes, and I do not meet the criteria in the categories above.

Are you currently under an obligation to quarantine, isolate, and/or self-monitor due to COVID-19 at the direction of any doctor, hospital, public health official, or other competent authority?

No.
Yes.