COVID-19 Health screening

Full Name:*

First Name Last Name

Have you experienced any of the following symptoms in the past 48 hours?* Please select all that apply.

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?*

Yes No

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?*

Yes No

Are you currently waiting on the results of a COVID-19 test?*

Yes No

If your response to any of the following questions is YES, we ask you to please not attend CTeen for the time being.

Please confirm that should the answer to the above questions change, AFTER having submitted this form, please do not attend for the time being. Should you be showing symptoms of COVID-19 up to a week after attending a CTeen event, please notify us immediately so we may respond accordingly.

Signature:*

Date:*

Month Day Year