EmailMeForm
GCI Confidential Health Form
Full Name:
*
Phone Number:
*
###
-
###
-
####
E-Mail Address:
*
Have you returned from or traveled out of the United States in the last 14 days?
*
Yes
No
Have you had contact with anyone who has been confirmed by laboratory testing to have COVID-19 or anyone who is currently being tested?
*
Yes
No
Are you being actively monitored or observed by any local, county, state or federal public health agency due to risk of Coronavirus?
*
Yes
No
Are you experiencing any of the following?
Fever?
*
Yes
No
Cough?
*
Yes
No
Respitory Distress?
Yes
No