COVID-19 Online Questionnaire

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Date of Submission
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Time of Submission

: Hours

Minutes

AM/PM
Name*
First Last
Which facility is your class located?*
Date of the Class (must be completed ON THE DAY OF YOUR CLASS. Early submissions will not be accepted.)*
MM slash DD slash YYYY
Email*
Have you, or anyone in your family, been in contact with a person that has tested positive for COVID-19 in the last 14 days?*
Have you been medically directed to self-quarantine due to possible exposure to COVID- 19 in the last 14 days?*
Are you having trouble breathing or have you had flu or cold-like symptoms within the past 72 hours, including: fever, cough, shortness of breath, difficulty breathing, sore throat, stuffy nose, loss of the sense of taste or smell, body aches, chills, headache, nausea/vomiting or fatigue?*
Do you agree to report the onset of any cold/flu-like symptoms during your time on site?*