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2. Have you been in close contact with anyone who has tested positve for or had sympotms of COVID-19? (close contact means being with 6 feet for more than 10 mins) ?*

   1. YES
   2. NO
3. Have you traveled internationally or out-of state to any state beyond the border states (NJ, CT, PA, MA, VT), for more details about travel restrictions.*

   1. YES
   2. NO
5. In the past 24 hrs, have you experienced any COVID-19 related symptoms such as: *

   Fever of 100 F or higher or chills; dry Cough or congestion (unrelated to allergies); shortness of breath or trouble breathing (unrelated to asthma & exercising); nausea, vomiting or diarrhea; or loss of taste or smell

   1. YES
   2. NO
6. In the last 24 hours, have you tested positive for COVID-19?*

   1. YES
   2. NO
8. If you selected more than None or neither, please stay at home, contact Jim or Yolanda and look for a sub to cover your shift and contact your healthcare provider for further guidance.
9. Confirmation *
   Please confirm you read all of the above questions and answered to the best of your knowledge by placing your initials in the box. Then "submit" this form.
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11. 1. Receive an email copy of this form.
12. Email address

    This field is not part of the form submission.

13. Submit

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