Health Check 1. Is your temperature 100.4 F or higher today?* Yes No 2. Do you feel sick today?* Yes No 3. In the last 14 days have you experienced any COVID-19 symptoms (such as fever of 100.4 F or more, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea)?* Yes No 4. In the last 14 days, have you travelled internationally or visited any U.S. State other than New Jersey? If yes, please specify where.* Yes No Specify Location(s): 5. Have you tested positive for COVID-19 within the last 14 days?* Yes No 6. Have you been in close contact with a suspected or confirmed case of COVID-19 in the last 14 days?* Yes No I certify that all information provided is shared to the best of my ability.Legal Name First Last I certify that all information provided is shared to the best of my ability.* Yes Date MM slash DD slash YYYY
