Self Reporting Illness Form

First name *

Last name *

Email *

I am a: *

Address *

City *

State*

Zip*

Phone Number*

Have you traveled internationally in the last three months?*

Yes

No

Have you traveled outside North Carolina in the last three months?*

Yes

No

Where and when?*

Were you exposed to anyone who was ill or suspected of being ill?*

Yes

No

Unsure

Please select which, if any, of the symptoms you are experiencing:

Fever

Fatigue

Body Aches

Cough

Shortness of Breath

History of travel

Exposure to others

Other

Have you seen a doctor?*

Yes

No

Do you suspect you have been exposed to a contagious disease? *

Yes

No

Additional Comments:

Please inform us of any related information