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Mountain View Vision Covid Questionaire
Berenice
2022-05-17T02:03:07+00:00
Mountain View Vision Covid Questionaire
First name
Last name
Date:
MM slash DD slash YYYY
Please answer the following questions regarding COVID-19 in accordance with OSHA regulations.
1. Are you experiencing any symptoms such as fever, shortness of breath, headache, sore throat, or loss of smell or taste?
Yes
No
2. Has anyone in your household experienced any of the symptoms above in the past 14 days?
Yes
No
3. In the past 14 days, have you been in close contact of someone with suspected or confirmed COVID-19?
Yes
No
4. In the past 14 days, have you tested positive for COVID-19?
Yes
No
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