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

First Name:
Last Name:

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 14 days? Are you waiting to receive the results of a COVID-19 test?
Have you been asked to self-isolate or quarantine by a health care provider or a local public health official?
Have you or anyone in your household travelled inter-nationally in the past 14 days to countries with widespread, sustained community transmission?
Are you required to quarantine to comply with the Massachusetts COVID-19 Travel Order, due to travel to non-lower-risk states, for reasons not exempted by the Order?
All questions must be answered before submitting