COVID Compliance Form

COVID Compliance Form

Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Cell*
Temperature*
Do you suffer from any of the following symptoms?
Fever*
- Yes
- No
Dry Cough*
- Yes
- No
Shortness of Breath*
- Yes
- No
Sore Throat*
- Yes
- No
Signature
I hereby acknowledge that my answers to the questions above were truthful.