OPA Staff Screening Survey

Please review and complete the form below.

First Name

Please enter your first name.

Last Name

Please enter your last name.

Phone Number

Please enter your phone number.

Email Address

Please enter your email address.

Have you experienced any COVID-19 symptoms in the past 14 days?
Fever (temperature of 100°F or above) or chills, body aches, cough, shortness of breath, sore throat, nasal congestion, nausea, vomiting, diarrhea, loss of taste and/or smell. Please answer 'yes' only if you are experiencing a new onset of symptoms OR you are experiencing a change in symptoms from your own baseline if you have preexisting medical conditions (e.g. allergies, asthma)

Please select an option.

Have you tested positive for COVID-19 in the past 14 days?

Please select an option.

Have you been in close contact with a confirmed or suspected COVID-19 case in the past 14 days?

Please select an option.

Please confirm your not a robot.

Remember my information.