*Note that symptoms of COVID-19 include, but are not limited to: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, or new loss of taste or smell. Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19?* Yes No Have you tested positive for COVID-19 in the past 14 days?* Yes No Have you experienced any symptoms of COVID-19 in the past 14 days?* Yes No Name* First Last Email* PhoneThis field is for validation purposes and should be left unchanged. Δ You are required to notify Eric Kugler, email@example.com, immediately if your answers to the above questions change at any time, such as if you start to experience any symptoms of COVID-19.