Health and Safety Questionnaire
Purpose for Visit?
Please select:
Volunteer
Staff Visit
Contractor
Basic Information
First Name:
Last Name:
Email Address:
Preferred Phone:
Phone Type:
Home
Work
Cell
Have you experienced any of the following in the last 14 days (Check all that apply)
Fever or Chills
Shortness of Breath
Fatigue
Headache
Sore throat
Nausea or vomiting
Cough
Difficulty Breathing
Muscle or body aches
New loss of Taste or Smell
Congestion or runny nose
Diarrhea
None
Gender
Male
Female
Have you traveled outside of Maryland in the last 14 days?
Select Yes or No
Yes
No
To your knowledge, have you been in close contact with a person who has a confirmed case of COVID-19?
Select Yes or No
Yes
No