Name *

First Name

Last Name

Phone *

(###)

###

####

Question 1 *

In the last 48 hours have you had any of the following symptoms (please answer "NO SYMPTOMS" if you have no symptoms)

No Symptoms

Fever 100.4 or higher

Cough

Sore Throat

Diarrhea

Nausea or Vomiting

New Loss of Sense of Smell and/or Taste

Chills

Muscle Pain or Body Aches

Headache

Shortness of Breath or Difficulty Breathing

Fatigue

Congestion or Runny Nose

Question 2 *

Within the last 14 days have you been diagnosed with COVID-19 or had close contact (6 feet or closer for a cumulative total of 15 minutes without personal protection equipment) with someone who has tested positive for COVID-19?

Yes

No

Question 3 *

Within the last 3 months, were you previously diagnosed with laboratory confirmed COVID-19 and have since recovered?

Yes

No

Question 4 *

Are you fully vaccinated (i.e. ≥2 weeks following receipt of the 2nd dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine)?

Yes

No

Question 5 *

Within the last 10 days, have you traveled internationally?

Yes

No

Question 6 *

If you answered yes to question 5 then you must answer this question. Did you have negative PCR COVID test 1-3 days prior to arrival in NY or NJ States?

Yes

No

Skip Question

Question 7 *

If you answered yes to question 5 then you must answer this question. Did you quarantine 7 days upon arrival in NY / NJ States?

Yes

No

Skip Question

Question 8 *

If you answered yes to question 5 then you must answer this question. Did you repeat negative PCR COVID test 3-5 days after arriving in NY / NJ States?

Yes

No

Skip Question

Question 9

Within the last 10 days, have you traveled to any location outside of these listed for more than 24 hours - New York, Connecticut, New Jersey, Pennsylvania, Vermont, Massachusetts, or Canada?

Yes

No

Question 10

If you answered yes to question 9 then you must answer this question. Did you have a negative PCR COVID test 1-3 days prior to arrival to NY / NJ State?

Yes

No

Skip Question

Question 11

If you answered yes to question 9 then you must answer this question. Did you quarantine 7 days upon arrival?

Yes

No

Skip Question

Question 12

If you answered yes to question 9 then you must answer this question. Did you have to repeat a negative PCR COVID test 3-5 days after arriving in NY / NJ State?

Yes

No

Skip Question