Visitor COVID-19 Questionnaire

Visitor Name*

Answer Required

Temperature (If you have fever of a 100.4 degrees Fahrenheit or greater, you MUST stay home).

Answer Required

Have you had contact with anyone diagnosed with confirmed Coronavirus (COVID-19) in the past 14 days?*

Answer Required

Yes

Name of responsible party completing this survey*

Answer Required

Contact Phone Number*

Number Required

If you answered YES to any of the above questions, PLEASE EMAIL GEANA CHAPP GCHAPP@KOMAREK94.ORG IN THE HEALTH OFFICE FOR FURTHER INSTRUCTIONS.

Thank you for completing this COVID-19 questionnaire.

Please fix the highlighted areas below before submitting.