EmailMe Form - COVID-19 Status Update

Name *

First Last

Email *

Phone *

### - ### - ####

Today's Date *

MM / DD / YYYY

Date of reported activity *

MM / DD / YYYY

Do you or someone in your household have any of the following symptoms?

I am reporting: *

COVID-19 Screening Failure

Positive COVID-19 diagnosis

Negative COVID-19 diagnosis

Close contact with someone diagnosed with COVID-19

Travelled to a COVID-19 afected area in the past 14 days

Other

Quarantine notice

I have received new or updated isolation orders

Date of Quarantine Expiration

MM / DD / YYYY

Look for emergency warning signs for COVID-19.

If someone is showing any of these signs, seek emergency medical care immediately:

-Trouble breathing
-Persistent pain or pressure in the chest
-New confusion
-Inability to wake or stay awake
-Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone

Call your medical provider for any other symptoms that are severe or concerning to you.