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* 1. Please enter your first and last names and Date of birth

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* 2. Have you or anyone in your household had any of the following symptoms in the past 21 days: sore throat, cough, chills, body aches for unknown reason, shortness of breath for unknown reason, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?

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* 3. Have you or anyone in your household been tested for COVID-19?

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* 4. Have you or anyone in your household  visited or received treatment in a hospital, nursing home, long term care, or other healthcare facility in the past 30 days?

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* 5. Have you or anyone n your household travelled anywhere in the US or abroad in the past 21 days?

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* 6. Have you or anyone in your household travelled on a cruise ship in the past 21 days?

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* 7. Are you or anyone in your household a health care provider or first responder?

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* 8. Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

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* 9. Do you have any reason to believe that you or anyone in your household has been exposed to or acquired COVID-19?

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