Safe Trace Screening

Thank you for attending the XYZ 2021 Annual Conference. Due to public health and safety precautions, we are required to ask all attendees the following COVID-19 related questions. Please select the correct answer for each and click submit whenever you are finished.

Have you experienced any of the following symptoms in the past 48 hours:

• Fever or chills
• Cough
• Shortenss of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore Throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

Yes

Within the past 14 days, have you been in close physical contact(6 feet or closer for a cumulative total of 15 minutes) with:

• Anyone who is known to have laboratory-confirmed COVID-19?
Or
• Anyone who has any symptoms consistent with COVID-19?

Yes

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

Yes

Are you currently waiting on the results of a COVID-19 test?

Yes

Example: *Phone (555-555-5555)

Optional disclaimer checkbox

This can be an additional marketing or information checkbox if needed

This can be an additional text box if needed

In an effort to reduce the risk of COVID-19 exposure to [Company name] attendees, employees and suppliers, all participants are required to complete the following screening questionnaire.

This screening questionnaire does not provide a medical diagnosis and is for screening and informational purposes only. The information contained in the screening questionnaire is not intended to diagnose, cure, mitigate, treat, or prevent disease or other conditions. The questionnaire is not intended to provide a determination or assessment of an individual’s health. Anyone with health concerns, or concerns about the health of another, should consult a physician. If you are experiencing a health emergency, please call 911.

By clicking I AGREE below you indicate that you have reviewed and agree to the above disclaimer and our terms of use, available here.