Hale COVID-19 Tracking Form

Name *

First

Last

Have you had close contact with anyone that has a confirmed or suspected COVID-19 case in the past 14 days? *

Have you had a positive COVID-19 test in the past 14 days? *

Have you had any COVID-19 symptoms in the last 14 days? (copy) *

If you answered yes to having COVID-19 symptoms, please answer

Check all that apply

Have you been out of New York State? *

If you have been out of state, please indicate the state you visited

Please initial to testify to the truth of your response *

Date *

Message