Name *

First Name

Last Name

Date *

MM

DD

YYYY

Will you be on an ABA Site Today? *

Yes

No

Have you had any of these symptoms today? *

Fever > 100.0 F, chills Muscle pains or aches (not due to exercise) Cough (more than usual) Shortness of Breath or trouble breathing headache (more than usual) scratchy or painful sore throat nausea/vomiting/diarrhea/stomach cramps Dizziness and lightheadedness Sneezing, running nose or congestion (more than usual) Fatigue that is unusual or more severe than normal Eyes are unusually red and painful

Yes

No

Do you live with or have you had close contact with anyone who has tested positive for COVID-19 in the past (7) days? *

Yes

No

Are you fully vaccinated against COVID-19?

Yes

No

Have you had a POSITIVE COVID test by nasal swap, oral swap or saliva in the past (7) days? *

Yes

No