JCS Volunteer Health Questionnaire

First Name

Last Name

According to the U.S. Centers for Disease Control and Prevention & the World Health Organization, COVID-19 Symptoms include:

Are you experiencing any of the COVID-19 related symptoms noted above?

Yes
No

Are you living with or caring for an individual who is a suspected or confirmed case of COVID - 19?

Yes
No

Have you been in contact with anyone known or suspected to have COVID - 19 in the last 14 days?

Yes
No

Have you tested positive for COVID-19 in the last 14 days?

Yes
No

I certify all the information provided is true and correct to the best of my knowledge.

Date