Allyna Steinberg

Name *

First Name

Last Name

Phone *

(###)

###

####

Have you received the COVID-19 vaccine? *

No

One shot, Moderna or Pfizer (partially vaccianted)

One shot, Johnson & Johnson (fully vaccianted)

Two shots, Moderna (fully vaccianted)

Two shots, Pfizer (fully vaccianted)

Date of your last COVID-19 vaccine (enter 99/99/9999 if not applicable) *

MM

DD

YYYY

Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, or shortness of breath that began within the past 10 days? *

No

Yes

Yes, but I have received a negative result from a COVID-19 molecular diagnostic test since the onset of symptoms and have been fever free for 24 hours without the use of fever-reducing medication. [The negative result must be form a molecular diagnostic test, not antigen or antibody test.]

Have you tested positive for COVID-19 from a test that used a nose or throat swab or saliva (not a blood test) within the past 10 days? *

10 days measured form the day you were tested, not form the day when you got the result

Yes

No

Have you knowingly been in close contact (within 6 feet for at least 10 minutes over a 24 hour period) with anyone while they had COVID-19 in the past 10 days? *

Yes

No

Have you tested positive for COVID-19 in the past 14 days? *

Yes

No

Have you traveled by public transportation (train, bus, plane, cruise, etc) in the past 14 days? *

Yes

No