1. Are you experiencing any flu like symptoms, such as chills, cough, and shortness of breath or body aches? YesNo
If yes, please mention the accurate date when it first appears.
2. Is any member of household displaying symptoms? YesNo
If yes, please mention the date of their symptoms appear.
3. Have you been in contact with anyone who has tested positive for COVID-19? YesNo
If yes, when?
4. Have you travelled internationally in the past 14 days? YesNo
If yes, when and where?
5. Do you use PPE (masks, gloves, sanitizer, etc.) while in public spaces, such as grocery stores? YesNo
6. Is your body temperature above 38 degree celsius? YesNo
