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

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?
• Anyone who has any symptoms consistent with COVID-19?

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?

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

Example: *Phone (555-555-5555)