Name *

First Name

Last Name

I have not experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, or shortness of breath within the past 10 days

In the past 10 days, I have not tested positive for COVID-19 using a test that tested saliva or used a nose or throat swab (not a blood test)? (10 days measured from the date you were tested, not the date you received the test result.)

To the best of my knowledge, in the past 14 days, I have not been in close contact (within 6 feet for at least 10 minutes) with anyone while they had COVID-19

In the past 14 days, I have not traveled internationally or returned from a state identified as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)?

I am not currently waiting on the results of a COVID-19 test