COVID Questionnaire 3D Innovations

Your Information
Name*
First Last
Email*
Phone*
1. Have you had a fever over 100 degrees F within the last 24 hours?*
- Yes
- No
2. Have you had any close contact in the last 14 days with someone diagnosed with COVID-19 or suspected of having COVID-19?*
- Yes
- No
3. Is anyone in your household awaiting results from a recently taken a COVID-19 test?*
- Yes
- No
4. Has anyone in your household traveled within the last 14 days and/or been subject to quarantine?*
- Yes
- No
Consent*
I agree to having my information provided to the Department of Health for contract tracing should the information need to be provided.
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