This form should be submitted prior to arriving at JRC. Your temperature will also be taken upon arrival.

First Name:
Last Name:
Email:
Phone#:

If visiting a Student/Client please list their name(s):

Today or in the past 24 hours, have you had any of the following symptoms in a way not normal to you: Fever (temp. of 100.0°F or above? Felt feverish or alternating sweats and chills or shaking? Cough? Shortness of breath/difficulty breathing/rapid breathing? Sore throat? Fatigue? Gastrointestinal symptoms (diarrhea, nausea, vomiting, abdominal pain)? Unexplained rash? Headache? Flushed cheeks? New nasal congestion or new runny nose? New loss of smell/taste? New muscle or body pain/aches? Any other sign of illness? (While other illnesses may not be COVID-19, they may facilitate the transmission of the virus.)
Have you taken medicine within the last 24 hours to lower a fever?
Have you or anyone in your household had close contact with someone in the previous 14 days with a confirmed or presumptive diagnosis of COVID-19 or someone who is ill with a respiratory illness?
Have you tested positive for COVID-19 within the past 10 days? Are you waiting to receive the results of a COVID-19 test?
Are you currently required to quarantine or to be in isolation following a request or direction made by a health care provider or a local public health official?
Have you or anyone in your household travelled internationally in the past 10 days to countries with widespread, sustained community transmission?
Are you currently required to quarantine because you traveled internationally or to a high-risk state within the past 10 days? Unless your international travel or your travel to or from a high-risk state meets the criteria of one of the exemptions listed on Mass.gov, the Massachusetts COVID-19 Travel Order requires you to quarantine for 10 days or present a negative COVID-19 test result that was administered up to 72-hours before you arrived in Massachusetts.
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All questions must be answered before submitting