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Covid Safety
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Scan Date:
*
format: 03/27/14.
Scan Time:
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Group Name:
*
Researcher's Name:
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Symptom Free
*
Yes
No
In the last 30 days, have you had a positive COVID-19 test?
*
Yes
No
In the last 14 days, have you had sustained close contact (such as a household contact) with a person with a positive COVID-19 test?
*
Yes
No
In the last 14 days, have you had a fever, cough or diarrhea?
*
Yes
No
In the last 14 days, have you had cold or flu like symptoms?
*
Yes
No
In the last 14 days, do you have concerns regarding other potential symptoms (loss of taste, loss of smell, eye redness or discharge, confusion, dizziness, unexplained muscle aches) related to COVID 19?
*
Yes
No
Is the participant’s temperature >=100.4F / 38C when measured at BMC?
*
Yes
No
Notes: