COVID-19 Screening

1. How old are you?

Under 18

Between 18 to 65

Above 65

2. Are you experiencing any of these symptoms?

Select all that apply

Fever, chills, or sweating

Diffculty breathing (not severe)

New or worsening cough

Sore throat

Aching throughout the body

Vomiting or diarrhea

None of the above

3. Do you have any of these conditions?

Select all that apply

Asthma or chronic lung disease

Pregnancy

Diabetes with complications

Disease or conditions that make it harder to cough

Kidney failure that needs dialysis

Cirrhosis of the liver

Weakness immune system

Congestive heart faliure

Extreme obesity

None of the above

4. In the last 14 days, have you traveled internationally?

I have traveled internationally

I have not traveled internationally

5. In the last 14 days, have you been in an area where COVID-19 is widespread?

Select all that apply

I live in an area where COVID-19 is widespread

I have visited an area where COVID-19 is widespread?

I don't know

None of the above

6. In the last 14 days, what is your exposure to other who are known to have COVID-19?

Select all that apply

I live with someone who has COVID-19

I've had close contact with someone who has COVID-19

(For 10 minutes, I was within 6 feet of someone who's sick or exposed to a cough or sneeze.)

I've been near someone who has COVID-19

(I was at least 6 feet away and was not exposed to sneeze or cough.)

I've had no exposure

(I have not been in contact with someone who's sick.)

7. Do you live or work in a care facility?

This includes a hospital, emergency room, other medical setting or long-term facility.

I live in a long-term care facility

(This includes nursing homes or assisted living.)

I have worked in a hospital or other care facility in past 14 days

(This includes volunteering.)

I plan to work in a hospital or other care facility in the next 14 days

(This includes volunteering.)

No, I don't live or work in a care facility

COVID-19 Screening Tool