Are you experiencing any of the following symptoms:


  • Extreme difficulty breathing
  • Blue-colored lips or face
  • Pain or pressure in the chest
  • Dizziness or confusion
  • None of these

Are you experiencing any of these other symptoms:


  • Fever or feeling feverish
  • Shortness of breath
  • Cough
  • Body aches
  • Other
  • None of these

According to the CDC, individuals with certain underlying medical conditions might be at increased risk for severe illness from COVID-19 Do you consider yourself as being in one of these high-risk categories?


  • Yes
  • No

In the past fourteen (14) days, have you had close contact with someone who is confirmed as having COVID-19?

A close contact is defined as a person who:


  1. had close physical contact without consistent and appropriate use of masks and social distancing, or who provided care for the individual, including healthcare workers, family members or other caregivers, OR
  2. lived with or otherwise had close contact (within 6 feet) for more than 15 minutes with the person while they were infectious OR
  3. had direct contact with infectious bodily fluids or respiratory droplets of the person (e.g. was coughed or sneezed on) while not wearing recommended personal protective equipment such as a face mask.


  • Yes
  • No