Seals of the Court of Appeals and Superior Court
District of Columbia Courts
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Health Screening Questionnaire Form

Symptoms in the Last Seven Days

* 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?
Have you been close to someone with a fever

* Within the past 14-days, have you been in close physical contact (6-feet or closer for a total of 15-minutes) with anyone who has tested positive for COVID-19, or anyone who has symptoms of COVID-19?

Covid Positive

* 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?