COVID-19 QUESTIONAIRE

Please fill out the following form in order to participate in our activity.

Full Name

Date of Birth

Have you tested positive for COVID-19 in the past 10 days? *

Yes

Have you had a fever (100.0°F or greater) in the last 24 hours? *

Yes

Have you had close contact with someone with a confirmed positive COVID-19 in the past 10 days? *

Yes

If you have traveled out of the country within the last 10 days, did you get a negative COVID test result taken between 3 to 5 days after arrival and quarantined for 7 days? *

Yes

Do you currently have any of the symptoms below? ● Fever (100.0°F or greater) or chills ● Congestion or runny nose ● Cough ● Sore throat ● Fatigue ● Headache ● Muscle or body aches ● Shortness of breath or difficulty breathing ● New loss of taste or smell ● Nausea or vomiting ● Diarrhea *

Yes

If you answered YES to any of the questions above, you are NOT allowed to enter the building.

Your signature below indicates that you have answered the above questions truthfully

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Phone: 470-567-6719
Fax: 470-805-1664

***By Appointment Only***

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COVID-19 QUESTIONAIRE

If you answered YES to any of the questions above, you are NOT allowed to enter the building. Your signature below indicates that you have answered the above questions truthfully

If you answered YES to any of the questions above, you are NOT allowed to enter the building.

Your signature below indicates that you have answered the above questions truthfully