Covid Screening Pakmen Courts

All fields are REQUIRED

First Name* Last Name* Phone Number* Email Address* Program Name* Program Start Time*

Are you sick with a cold/flu or are you displaying any signs of COVID-19 and/or flu-like symptoms?
Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?
Have you returned from outside the country (including Canada / USA) in the past 14 days?
In the past 14 days, at work or elsewhere, did you have close contact with someone who has a probable or confirmed case of COVID19?
In the past 14 days, at work or elsewhere, did you have close contact with a person who had acute respiratory illness that started within 14 days of their close contact to someone with a probable or confirmed case of COVID-19?
In the past 14 days, at work or elsewhere, did you have close contact with a person who had acute respiratory illness who returned from travel outside of the country in the 14 days before they became sick?
In the past 14 days have you been directed by Public Health to self-isolate?

Do any of the above questions apply to you?* Yes No