Have you had any of the following in the last 48 hours?
BODY ACHES (new or not expected)
FATIGUE (not chronic or normal for you)
FEVER (or feeling feverish)
HEADACHE (not chronic or normal for you)
NAUSEA OR VOMITING
NEW COUGH (not related to chronic condition)
RECENT LOSS OF TASTE OR SMELL
RUNNY NOSE OR STUFFY NOSE (not related to seasonal allergies)
SHORTNESS OF BREATH OR DIFFICULTY BREATHING
Have you traveled to Rhode Island for a non-work-related purpose from another city, town, county, or state that currently has a stay-at-home restriction, a shelter-in-place restriction, or a similar restriction, declaration, or announcement due to a COVID-19 outbreak?
I have been directed to isolate or quarantine by the Rhode Island (or any other state) Department of Health or a healthcare provider in the past fourteen (14) days
I have been in close contact (less than six (6) feet) with anyone diagnosed with COVID-19 or experiencing the symptoms above without Personal Protective Equipment (PPE)
I have traveled outside the Fifty (50) United States in the past fourteen (14) days?
I attest that I have had none of the above symptoms or risk factors
Please add your intials below then send form.