RPAI | Entry Survey

Name (First & Last)*

Name (First & Last)

Cell Phone Number*

Cell Phone Number

Company*

Company

Who are you here to visit?

Which center are you visiting (optional)

Question 1:

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)?

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)?*

No
Yes - Do not enter the office

Question 2:

In the past 14 days, have you tested positive for COVID-19?

In the past 14 days, have you tested positive for COVID-19?*

No
Yes - Do not enter the office

Question 3:

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?

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?*

No
Yes - Do not enter the office

Question 4:

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?

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?*

N/A - I do not live in Cook County, IL
No
Yes - Do not enter the office

Question 5:

In the past 14 days, have you attended a social gathering or event that consisted of 50 or more individuals?

In the past 14 days, have you attended a social gathering or event that consisted of 50 or more individuals?*

No
Yes - Do not enter the office

Consent:

Consent*

I agree that all of my responses are truthful and accurate.

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