Full Name Position/Role Organization Date

Have you experienced any of the following symptoms in the past 14 days? (Fever, cough, shortness of breath, sore throat, loss of taste/smell, etc.) No Yes If yes, please specify

Have you been in close contact with a confirmed or suspected case of infectious disease in the past 14 days? No Yes If yes, please specify

Do you have any chronic medical conditions (e.g., diabetes, hypertension, asthma, etc.)? No Yes If yes, please specify

Are you currently taking any medications? No Yes If yes, please specify

Are your vaccinations up to date? Yes No

Additional Remarks