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Health Screening Questionnaire Form Public

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To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. The information on the form will be kept for 14-days, to assist the DC Department of Health with any necessary contact tracing. Thank you for your time.

Health Screening Questionnaire Form

* Have you experienced cough, shortness of breath/difficulty breathing, or two or more of the following symptoms in the past 48-hours:

Fever or chills?
Muscle or body aches?
New loss of taste or smell?
Congestion or runny nose?
Diarrhea?

Fatigue?
Headache?
Sore throat?
Nausea or vomiting?

Yes

* Within the past 5-days, have you tested positive for COVID-19, or been in close physical contact (6-feet or closer for a total of 15-minutes) with anyone who has tested positive for COVID-19?

Yes

* Are you currently isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

Yes

The demographic information below will be kept confidential and will only be shared with the DC Department of Health if contact tracing is necessary. The information will be kept for 14 days and will be destroyed after that period.

First Name

Last Name

Email Address

Phone

Area of Courthouse/Courtroom Visiting

Health Screening Questionnaire Form

"Open to All, Trusted by All, Justice for All"

District of Columbia Courts | (202) 879-1010

"Open to All, Trusted by All, Justice for All"

District of Columbia Courts | (202) 879-1010