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Regardless of your vaccination status, have you experienced any of the symptoms in the list below in the past 48 hours?

IMPORTANT: ANSWER “YES” EVEN IF YOU BELIEVE THE SYMPTOM(S) IS BECAUSE OF SOME OTHER MEDICAL CONDITION (FOR EXAMPLE, ANSWER “YES” IF YOU HAVE A RUNNY NOSE BECAUSE OF ALLERGIES).

  • fever or chills
  • cough
  • shortness of breath or difficulty breathing
  • fatigue
  • muscle or body aches
  • headache
  • new loss of taste or smell
  • sore throat
  • congestion or runny nose
  • nausea or vomiting
  • diarrhea

Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?

Please select an answer

Are you fully vaccinated?*

AND/OR

Have you recovered from a documented COVID-19 infection in the last 3 months?

*To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine.

Please select an answer

Have you been in close physical contact* in the last 14 days with:

  • anyone who is known to have laboratory-confirmed COVID-19?
  • OR
  • anyone who has any symptoms consistent with COVID-19?

*Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection).

Federal employees who make a false statement on this form could be subject to an adverse personnel action, up to and including removal from their position. It is also a federal crime (18 U.S.C. § 1001) for anyone to provide false information on this form. Falsification could also affect continuing eligibility for access to classified information or for employment in a national security position under applicable adjudicative guidelines. 

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