COVID – 19 Reporting

Visitor Information

First Name *

Last Name *

Email *

Phone *

Reason for visiting Tulsa CARES *

Expected date of arrival to Tulsa CARES *

Travel History

Have you traveled or resided outside of Oklahoma within the last 14 days? *

Yes

No

Where did you travel to? *

Event Attendance

Have you attended an event/entertainment venue/gathering or group of greater than 10 people in the last 14 days? The people in your household do not count towards the 10 people. *

Yes

No

Please describe the event *

Symptom Information

Have you experienced any symptoms within the last 14 days? *

Yes

No

Exposure Information

Have you had direct contact with Confirmed (+) COVID-19 within the last 14 days? *

Yes

No

When did the individual you were in contact with get a positive diagnosis? *

Have you had direct contact to someone awaiting COVID-19 test results within the last 14 days? *

Yes

No

Were they experiencing symptoms? If so, when did symptoms begin? *

Do you share a household with anyone who has had symptoms of concern for COVID-19 within the last 14 days? *

Yes

No

Do you share a household with anyone who has been instructed to Self-Isolate within the last 14 days? *

Yes

No

Do you share a household with anyone who has been diagnosed with COVID-19 within the last 30 days? *

Yes

No

Have they been deemed non-contagious by a healthcare professional? *

Testing Information

Have you tested POSITIVE for COVID-19 within the last 20 days? *

Yes

No

Acknowledgement

The information submitted on this form is complete and accurate to the best of my knowledge.

I acknowledge that this screening tool is being used for clearance to visit Tulsa CARES for the specified reasons and dates stated within this form, based on information I provided. It is not intended for use regarding personal medical evaluation, advice, decisions, and/or treatment. Seek care from your primary care provider or emergency services, as appropriate, for any personal medical needs.

I understand this information is being collected for the purpose of infection prevention and public/employee safety.

*

I Agree

COVID-19 Screening