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2. CITY OF MANVEL_COVID-19 SCREENING FORM
5. 
6. This form shall be used on ALL persons before entering City Hall. This form is to help identify immediate potential risk. Persons who answer “YES” to the following questions should seek further evaluation.
8. First Name*
9. Last Name*
11. Email Address *
13. Contact Phone Number*
15. Review and answer all questions shown below
17. Have you traveled outside of the state of Texas within the last 14-days?
18. No

    1. No
19. Yes

    1. Yes
21. Have you been in close contact with anyone who has been lab-confirmed to have COVID-19?
22. No

    1. No
23. Yes

    1. yes
25. Have you experienced any of these symptoms (within the last 5 days) that are new and not part of a chronic health condition, such as COPD or emphysema?
27. Cough
28. No

    1. No
29. Yes

    1. Yes
31. Shortness of breath or difficulty breathing
32. No

    1. No
33. Yes

    1. Yes
35. Chills
36. No

    1. No
37. Yes

    1. Yes
39. Repeated shaking with chills
40. No

    1. No
41. Yes

    1. Yes
43. Muscle Pain
44. No

    1. No
45. Yes

    1. Yes
47. Sore Throat
48. No

    1. No
49. Yes

    1. Yes
51. Fever-Greater than or equal to 100.4 degrees Fahrenheit
52. No

    1. No
53. Yes

    1. Yes
55. Loss of taste or smell
56. No

    1. No
57. Yes

    1. Yes
59. Diarrhea
60. No

    1. No
61. Yes

    1. Yes
63. FOR STAFF USE ONLY
65. BASED UPON THE RESPONSES, THIS PERSON IS NEGATIVE FOR RISK OF COVID-19
66. ___ No _____ Yes
68. BASED UP0N THE RESPONSES, THIS PERSON NEEDS FURTHER EVALUATION
69. ___ No _____ Yes
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

* indicates a required field