COVID-19 Screening Survey

Please answer the questions below to help determine eligibility.

  • 1Are you experiencing any of the following symptoms? (Select all that apply)
      • Are you experiencing SEVERE shortness of breath?
      • Please describe the symptoms you are experiencing.
  • 2Within the past 2 weeks have you had close contact (less than 6 feet for over 10 minutes) with someone who has tested positive for Coronavirus/COVID-19 or have you been notified by the CDC?
  • 3Is COVID-19 testing required for work clearance or a return to work status
  • 4Pre Op Clearance for surgery?
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