EmailMe Form - Community Epidemic Screening Statistical Table

1. Your name *

First Last

2. What is your age? *

3. Your home address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

4. Number of family members *

5. Your mobile phone number *

6. In the past two weeks, have you used the following transportation? *

7. In the past two weeks, have you travelled, transferred or stayed in Hubei Province? *

Please enter city *

8. In the past two weeks, have you had the following situations? *

Please enter city *

9. Recently, do your family members have symptoms such as fever, dry cough, fatigue, and difficulty breathing? *

Yes

No

10. Recently, have you noticed any noteworthy situations related to the epidemic in the community?

Yes (please elaborate)

No

Please elaborate *