Entry Survey

  • Name (First & Last)
  • Cell Phone Number
  • 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)?
  • Question 2:

    In the past 14 days, have you tested positive for COVID-19?
  • 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?
  • 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?
  • Question 5:

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