Daily Check-in Form [Example] Check-In Date: MM slash DD slash YYYY Enter your PIN#:* Enter your name:* First Last Since potential exposure, have you developed any of the following symptoms?*Check all that apply Fever Cough Difficulty Breathing Sore Throat Chills Repeated Shaking With Chills Muscle Pain Headache New Loss of Taste or Smell Congestion Runny Nose Nausea Diarrhea None of the Above Have your symptoms improved since yesterday?* Yes No Have you sought medical care?* Yes No Email Address* Enter your email address to receive a copy of this form.
