Health Declaration

Please enter your name and phone number for our contact tracing efforts. Thank you!

I hereby certify, represent, and warrant as follows:

Within the fourteen (14) days immediately preceding the date of the health declaration form, I have NOT:

1. Tested positive or presumptively positive for or been identified as an asymptomatic carrier of COVID-19;

2. Experienced any symptoms commonly associated with COVID-19;

3. Have been in direct contact with or the immediate vicinity of any person known or now known to have COVID-19.

This form will remain private and confidential unless it is necessary to contact trace any COVID-19 cases. Your information will not be used for any other purposes. You may take a screen shot for your records if you like.