In our efforts to minimize the transmission and spread of COVID-19, please complete the following questionnaire on behalf of yourself and all individuals within the home, prior to submitting your maintenance request.

1.) Have you or anyone within the home tested positive for COVID-19 within the last 5 days?	Yes No
2.) Within the last 5 days did you provide care or have contact with a symptomatic person known or suspected to have COVID-19?	Yes No
3.) Please select YES if you or anyone within the home are currently experiencing any of the following symptoms: Fever Chills Cough or worsening of chronic cough Shortness of breath Sore throat Runny nose Loss of sense of smell or taste Headache Fatigue Diarrhea Loss of appetite Nausea and vomiting Muscle aches Stuffy nose Conjunctivitis (pink eye) Dizziness, confusion Abdominal pain Skin rashes or discoloration of fingers or toes	Yes No

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