1. Have you experienced any of the following symptoms in the past 48 hours? (Check all that apply) Fever or chills Cough Shortness of breath None of the above

2. Have you been in close contact with someone diagnosed with a contagious illness in the last 14 days? Yes No

3. Have you traveled internationally or to a high-risk area in the last 14 days? Yes No

4. Additional Comments: