top of page
Home
About
COVID-19
Stimulus
Business Partners
eForms
Covid Screening
Referrals
Contact
FAQ
Feedback
More
Use tab to navigate through the menu items.
COVID SCREENING
Covid-19 Health
Declaration
First Name
Last Name
Email
Phone
I have not traveled outside of the state nor outside of of the country in the last 14 days.
I have not had a fever or lower repiratory symptoms such as a cough or shortness of breath.
I haven’t been in close contact with a Covid-19 patient in the last 14 days
I have not attended any events of 50 people or more.
I do not have any new onset symptoms such as a cough or runny nose.
I have not been asked to self-quarantine.
I declare that the information I have provided is accurate & complete.
Your Signature
Clear
Date
Submit
Thanks for submitting!
bottom of page
