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COVID Exposure Form
Name
Are you fully vaccinated? (Either two shots of Pfizer or Moderna or one shot of Johnson & Johnson) If yes, what was the date of your last shot?
Do you suspect you have COVID19 or were you exposed to someone with a confirmed positive COVID 19 diagnosis?
If exposed, was it a direct exposure (same room, unmasked for longer than 15 minutes) or indirect exposure? What date was the exposure?
Is the person you were exposed to symptomatic? When was their positive COVID test administered (exact date)? Was it a rapid or PCR Lab Test? Do they currently live in your home?
If you suspect you have COVID 19, have you been tested?
When/Where did you get tested?
Was that test negative or positive for COVID 19?
If positive, are you currently showing symptoms?
Do you currently have a fever?
If symptomatic, what date and approximate time did your symptoms start?
If symptomatic, are your symptoms severe enough to prevent you from working at full capacity?
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