COVID-19 SCREENING FORM Do you or have you had any of the following symptoms or signs? Check all that apply:* Fever Cough Shortness of breath No signs or symptoms Have you traveled outside of Panola county in the last 14 days?* Yes No In the past 14 days did you have close contact with someone who is suspect or COVID positive?* Yes No Name* First Last PhoneSignatureDate* MM slash DD slash YYYY
