COVID19 Screening Survey

List of COVID-19 self-assessment questions to determine if you were exposed to COVID-19 (novel coronavirus) or have symptoms.

Time to complete

2 minutes

Eligibility

Anyone who is experiencing symptoms of COVID-19 or has been in close contact with someone who has the virus is eligible to fill out the survey.

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Questions for COVID19 Screening Survey

1.

Did you shake hands with anyone today?

The answer should be a text input.
2.

Did you touch your face during the past hour?

The answer should be a text input.
3.

Have you been outdoors during the past hour?

The answer should be a text input.
4.

Has anyone sneezed on you or coughed near you during the last 12-hours?

The answer should be a text input.
5.

Did you share a drink with someone in the last hour?

The answer should be a text input.
6.

Have you been to any public areas during the past hour (e.g., airport, shopping mall, theater)?

The answer should be a text input.
7.

Did you receive a flu vaccine this year?

The answer should be a text input.
8.

Have you traveled outside of the country during the past month?

The answer should be a text input.
9.

Has anyone around you been ill with cold symptoms in the last week?

The answer should be a text input.

Similar Ideas

  • Covid 19 Exposure Form
  • Covid 19 Contact Form
  • Covid 19 Contact Tracing Form

Here are some FAQs and additional information
on
COVID19 Screening Survey

What is the purpose of the COVID19 Screening Survey?

The COVID19 Screening Survey is designed to help identify individuals who may have been exposed to the virus and who may be at risk for developing complications from the virus. The survey is not intended to diagnose individuals with the virus, but rather to help identify those who may need to be further evaluated by a healthcare provider.

How long does the COVID19 Screening Survey take to complete?

The COVID19 Screening Survey takes approximately 5 minutes to complete.

Who should take the COVID19 Screening Survey?

The COVID19 Screening Survey is intended for adults 18 years of age and older.

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