Name

First Name

Last Name

Phone

(###)

###

####

Are all of the eligible family members in your home vaccinated against Covid-19?

Yes

Please select your vaccination level (if vaccinated)

Have you traveled outside of the country in the last ten days?

Yes

Have you had visitors in your home in the last ten days?

If so, were they vaccinated and/or did they wear masks?

Have you held or have been to a gathering of more than five individuals in the last week?

If so, please describe what type of gathering, how many people, and if this was indoors or outdoors.