Name (First & Last)
Cell Phone Number
Who are you here to visit?
Which center are you visiting (optional)
Have you experienced any cold or flu-like symptoms in the last 14 days (including, but not limited to fever, cough, sore throat, respiratory illness, difficulty breathing, headache, and/or loss of taste or smell)?
In the past 14 days, have you tested positive for COVID-19?
In the past 14 days, have you been in close contact with anyone who either tested positive for COVID-19 or developed symptoms of COVID-19?
If you reside in Cook County, IL, within the past 14 days, have you traveled to a state on Cook County's quarantined list per the emergency travel order in place?
In the past 14 days, have you attended a social gathering or event that consisted of 50 or more individuals?