COVID SURVEY | Kobre Holdings

Have you or anyone living in your home experienced any cold or flu-like symptoms in the last 14 days or have experienced any of the following: fever, cough, difficulty breathing, sore throat, chills or repeated shaking with chills, pressure in the chest, extreme fatigue, earache, persistent headache, diarrhea, persistent loss of taste or smell, a purple rash on your feet or fingers or pinkeye?*

Yes
No

Have you or anyone living in your home received a lab-confirmed diagnosis for COVID-19 by a coronavirus (COVID-19) test or has received a positive diagnosis for COVID-19 by a health care professional in the past 14 days?*

Yes
No

Have you or anyone living in your home traveled by airplane internationally or domestically in the last 14 days?*

Yes
No

Have you or anyone living in your home been out of the area in the last 14 days?*

Yes
No

Have you or anyone living in your home had close contact with or cared for someone diagnosed with COVID-19 in the last 14 days?*

Yes
No

Have you or anyone living in your home had close contact during the past 14 days with any group of ten or more people besides people with whom they reside?*

Yes
No

Attestation*

I attest that this information is true, accurate and complete to the best of my knowledge.

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COVID-19 Employee Questionnaire

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