COVID Screening First Name(Required) Last Name(Required) Phone Number(Required) Email(Required) Have you or anyone in your household had a fever of 100.4 or higher during the past two weeks?(Required)Includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s) YesNoHave you or anyone in your household had a cough or unusual shortness of breath during the past two weeks?(Required)includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s) YesNoHave you or anyone in your household tested for COVID-19 during the past two weeks?(Required)includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s) YesNoHave you or anyone in your household traveled to a region/country considered high risk exposure to COVID-19 in the past two weeks?(Required)includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s) YesNoMore info, please review https://wwwnc.cdc.gov/travel/noticescovid19Has anyone in your household been exposed to anyone who has tested positive for COVID-19 in the past two weeks?(Required)Includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s) YesNoHave you received the COVID vaccine?(Required)NoYesHow many doses of the COVID vaccine have you received?(Required)One DoseTwo DosesBy signing below:(Required) I agree that I have entered honest and correct answers to the best of my knowledge. I agree that I must report changes to the information listed on this form prior to the start of each Face2Face class session Signature(Required)