First name
Last name
Email
Phone Number
Address
Have you received a complete COVID-19 vaccine series (i.e., 1 dose of Janssen, or 2 doses of Pfizer-BioNTech or Moderna)? yesno
[group vaccine-yes]
Please upload a picture of your vaccination card
Have you knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19? (Refer to Question 5 for a list of symptoms) yesno
Have you tested positive for COVID-19 through a diagnostic test in the past 14 days? yesno
Are you currently awaiting results from a COVID-19 test? yesno
Have you experienced any of the following symptoms in the past 14 days:
Fever or chills (fever of 100.4 degrees Fahrenheit (°F) or higher, or report feeling feverish) yesno
Cough yesno
Shortness of breath or difficulty breathing yesno
Fatigue yesno
Muscle or body aches yesno
Headache yesno
New loss of taste or smell yesno
Sore throat yesno
Congestion or runny nose yesno
Nausea or vomiting yesno
Diarrhea yesno
Have you traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 days? yesno [/group]
[group vaccine-no] Please explain you vaccination status [/group]
