Are you experiencing any of the following symptoms? Select... Cough Fever Sore throat Chest congestion Loss of smell or taste Difficulty in Breathing None of the Above

Have you ever had any one of the following: Select... Diabetes Hypertension Lung disease Heart disease Kidney disease Asthma None of the above

Have you travelled outside the State in the last 14 days? Select... Yes No

Which of the following applies to you? Select... I have recently interacted or lived with someone who has tested positive for COVID-19 I am a healthcare worker and I examined a COVID-19 confirmed case without protective gear. None of above.