In the past 14 days, have you tested positive for COVID-19? (Have you been tested?)

Yes
No

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

Yes
No

Are you currently experiencing, or have you experienced in the last 14 days, any of these symptoms: fewer, cough, shortness of breath or difficulty breathing, sore throat, loss of taste or smell?

Yes
No

In the last 14 days, have you been to a corona risk area?

Yes
No

CONFIRM SELECTION