Help us Finish Covid-19

What Is Today’s Date?

Is This An Initial Or Updated Submission

Contact Number

Alternate Contact Number

Best Method To Contact You

What Is Your Gender

Do You Have Any Medical Training?

Are You Certified In Any Of The Following?

First Aid

CPR

Blood-Borne Pathogen Certification

Do You Have Any Military Training?

Do You Have A Fever?

Do You Have Any Flu Like Symptoms?

If Yes, Which Of The Following?

Chest Cough

Thick Mucus

Runny Nose

Difficulty Breathing

Shortness Of Breath

Fatigue

Diarrhea

Who Is Your Primary Care Physician?

Do You Currently Have Medical Insurance?

Do You Take Any Medications?

If So, Please List Your Current Medications

Type Of Dwelling?

Single-Family

Multi-Family

Apartment

School Dormitory

Do You Own Or Rent?

How Many People Live In Your Household?

How Many Children Do You Have?

What Are The Ages Of The Children

1-3

3-5

5-7

7-9

9-11

11-13

13-15

15-17

17+

Does Any Person In Your Household Have A Fever?

Does Any Person In Your Household Have Flu-Like Symptoms?

If So, Which Of The Following Symptoms?

Chest Cough

Thick Mucus

Runny Nose

Difficulty Of Breathing

Shortness Of Breath

Fatigue

Diarrhea

Any Person In Your Household Tested Positive For Covid-19?

Your Work’s Name

Work Address

Work Zip

Work State

Nature Of Business

Your Position?

Owner’s Name

Owner’s Email Address

Owner’s Phone Number

Is This Business Considered Essential?

Number Of Co-Workers?

1-5

5-10

10-15

15-20

20-30

30-50

50+

Numbers Of Customers Served Daily?

1-5

5-10

10-15

15-20

20-30

30-50

50+

Number Of Customers In Personal Proximity Daily?

1-5

5-10

10-15

15-20

20-30

30-50

50+

Where Does Your Child Attend School (First School)?

First School Address

What Grade Is Your Child (First School)?

Where Does Your Child Attend School (Second School)

Second School Address

What Grade Is Your Child (Second School)?

Have Any Of Your Child(s) Classmates Tested Positive For Covid-19?

Do You Attend School?

If So, Please Provide School Address

School Zip Code

School State

Primary Method Of Traveling

Car

Uber/Lyft

Taxi

Bus

Train

If Traveling By Bus Or Train, Please List Your Route

Have You Been Outside Of Your State In The Last 30 Days?

If So, Where?

Zip Code

State

Have You Been Outside Of The State In The Last 30 Days (Continued)?

If So, Where (Continued)

Zip Code (continued)

State (Continued)

Have You Been Outside Of The Country In The Last 30 Days?

If So Where (please provide address)?

Please List Any Flight Itinerary

Purpose Of Your Trip?

Length Of Your Trip?

Please List The Business You Recently Visited #1

Date Of This Visit #1

Location Of This Visit #1

Please List The Business You Recently Visited #2

Date Of This Visit #2

Location Of This Visit #2

Please List The Business You Recently Visited #3

Date Of This Visit #3

Location Of This Visit #3