Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath that started in the past 10 days?

In the past 10 days, have you gotten a lab-confirmed positive result from a COVID-19 diagnostic test (not a blood test) that was your first positive result OR was AFTER 90 days from your previous diagnosis date? Please note that 10 days is measured from the day you were tested, not from the day when you got the test result.

Are you considered fully vaccinated against COVID-19 by CDC guidelines OR were you recently (within the past three months) diagnosed with COVID-19 and finished isolation in the past 90 days? Please note that to be considered fully vaccinated by CDC guidelines, two weeks must have passed since you received the second dose in a two-dose series or two weeks must have passed since you received a single-dose vaccine.

To the best of your knowledge, in the past 10 days, have you been in close contact (within 6 feet for at least 10 minutes over a 24 hour period) with anyone who is currently diagnosed with COVID-19 or who has been told they have symptoms of COVID-19? Clinical staff who were in appropriate personal protective equipment (PPE) are not considered close contacts in these scenarios.

Do you consent that a COVID-19 test can be administered to you?