Please complete prior to arriving

Phone*

I am completing this form:*

For myself
As a representative parent/guardian/caregiver

First name of person being checked in:*

Last name of person being checked in:*

Throughout this form, "you" will refer to the person listed here.

Around what time to you anticipate arriving today?*

:

1. Have you experienced any of the following symptoms in the past 48 hours:*

• fever or chills • cough • shortness of breath or difficulty breathing • fatigue • muscle or body aches • headache • new loss of taste or smell • sore throat • congestion or runny nose • nausea or vomiting • diarrhea

Yes
No

2. Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?*

Yes
No

3. Have you been in close physical contact in the last 14 days with anyone who has tested positive and/or has symptoms consistent with COVID-19?*

Yes
No

4. Are you currently waiting on the results of a COVID-19 test?*

Yes
No

5. Have you traveled out of the country in the past 10 days?*

Yes
No

Verification*

By checking this box, I attest that I have completed this form truthfully to the best of my knowledge.

Pre-screening for 2641 Maryland Ave., Baltimore, MD