Please answer honestly and to the best of your ability.

Thank you.

COVID-19 Screening Questions
Communication Preferences *

Have
- YOU,
- ANYONE IN YOUR HOUSEHOLD, or
- ANYONE WHO YOU HAVE BEEN IN CLOSE CONTACT WITH
(Close Contact = unable to maintain 6 feet of separation and were not wearing a face mask):

been caring for an individual who is quarantined due to exposure to COVID19 or traveling within the last 21 days? *
been tested for COVID-19 (is waiting for their result(s), or tested positive for COVID-19 within the last 30 days? *
had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches, shortness of breath, loss of smell, loss of taste, fever at/or greater than 100 degrees Fahrenheit? *
visited/worked or received treatment in a hospital, nursing home, rehabilitation center, long-term care, or other health care facility in the past 21 days? *
traveled to a neighbor island or outside of Hawaii within the last 14 days? *