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| Please provide your contact information. |
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| | Please confirm today's date. | |
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| | Have you traveled outside of the country within the past two weeks? | |
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Where have you traveled (abroad) within the past two weeks? |
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| | Please note any additional destinations or comments below. | |
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| | Have you traveled outside of your community within the past two weeks? | |
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Where have you traveled (domestically) within the past two weeks? |
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| | Please note any additional destinations or comments below. | |
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| | As far as you know, have you come into contact with anyone who has been diagnosed with the novel coronavirus/COVID-19? | |
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| | Please describe the context of this contact. | |
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| | Physically, how are you feeling today? | |
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| | A member of our team will review your responses and follow up as needed. Please share any additional comments, questions, or concerns that we might be able to help you with. | |
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