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Name
Facility
Have you experienced any of the following symptoms in the past 48 hours?
Yes
No
Fever or chills
Cough
Shortness or breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?
Yes
No
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
Yes
No
Are you currently waiting on the results of a COVID-19 test?
Yes
No
Did you answer NO to ALL questions?
Yes
No
Access
APPROVED
. Please show this to security at the facility entrance. Thank you for helping us protect you and others during this time.
Did you answer YES to ANY questions?
Yes
No
Access to CDC facilities
NOT APPROVED
. Please see page 2 for further instructions. Thank you for helping us protect you and others during this time.
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