Participant Name *

First Name

Last Name

Have you traveled off-island in the last 14 days? *

YES

NO

Are under evaluation for COVID-19 (for example, waiting for the results of a viral test to confirm infection), Or have been diagnosed with COVID-19 and not yet cleared to discontinue isolation? *

YES

NO

Have you been in close contact with anyone diagnosed with or under evaluation for COVID-19? *

YES

NO

Are you experiencing or have experienced in the last 24 hrs any “new” or “unexpected” symptoms from the list below? *

- Fever or feeling feverish (chills, sweating) - New cough - Difficulty breathing - Sore throat - Muscle aches or body aches - Vomiting or diarrhea - New loss of taste or smell

YES

NO