OPA Visitor Screening Survey

Please review and complete the form below.

First Name

Please enter your first name.

Last Name

Please enter your last name.

Phone Number

Please enter your phone number.

Email Address

Please enter your email address.

Company

Please enter your company.

Visit Purpose

Please enter the purpose of your visit.

Have you or a member of your household had a confirmed case of COVID-19?

Please select an option.

Date of positive test

Please enter the date.

Have you been cleared by a licensed health care provider to resume contact within established social distancing guidelines?

Please select an option.

Have you have been symptom free for at least 72 hours?

Please select an option.

Are you or any member of your household under active quarantine due to COVID-19 exposure?

Please select an option.

Have you or a member of your household been in contact with anyone who has a confirmed case of, or been exposed to COVID-19?

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Have you traveled outside of the U.S. within the past 14 days?

Please select an option.

Have you traveled to/from any domestic destinations currently with a COVID-19 travel advisory, during the past 14 days?

Please select an option.

Please Explain

Please enter additional information about your domestic travel.

Have you experienced any COVID-19 symptoms in the past 14 days?
Fever (temperature of 100°F or above) or chills, body aches, cough, shortness of breath, sore throat, nasal congestion, nausea, vomiting, diarrhea, loss of taste and/or smell Please answer 'yes' only if you are experiencing a new onset of symptoms OR you are experiencing a change in symptoms from your own baseline if you have preexisting medical conditions (e.g. allergies, asthma)

Please select an option.

Please Explain

Please enter additional information about your symptoms.

Please confirm your not a robot.

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