1. Have you experienced any of these symptoms in the past 10 days?

None of these symptoms

Fever or feeling feverish (e.g. chills, sweating)

Cough

Shortness of breath or difficulty breathing

New loss of taste or smell

2. Have you had a positive COVID-19 viral test result in the past 10 days?

Yes

No

3. Have you had interaction without a face covering with anyone with confirmed or suspected coronavirus within the last 14 days?

Yes

No

4. Have you traveled out of New York State in the past 14 days except to and from Canada?

Yes

No

5. Did you stay for more than 24 hours internationally, or in a state with wide community spread of COVID-19?

Yes

No

Which states have wide community spread of COVID-19?




Please answer all questions.