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2. First Name
3. Last Name
5. Do you have a fever greater than 100.4 degrees? *

   1. Yes
   2. No
6. Do you have any of the following symptoms: fever, cough, shortness of breath, sore throat or diarrhea?*

   1. Yes
   2. No
8. Do you have any of the following symptoms?

   1. Fever
   2. Chills
   3. Repeated shaking with chills
   4. Muscle Pain
   5. Headache
   6. Sore Throat
   7. Recent loss of taste or smell
   8. None of the above
9. Have you had close contact in the last 14 days with an individual diagnosed with COVID-19 and you are not fully vaccinated?*

   1. Yes
   2. No
11. Have you traveled internationally in the last 14 days? *

    1. Yes
    2. No
12. Do you have a face mask or face covering to allow entry into the building?*

    1. Yes, and I agree to wear the face mask or face covering properly, covering both my mouth and nose, while in the court building.
    2. No, I do not have a mask.
14. Temperature (Court to Process)
15. Signature (Court to Process)
17. __________________
18. _______________________
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19. 1. Receive an email copy of this form.
20. Email address

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21. Submit

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