Covid-19 Self Assessment

Get medical attention if:

1. Feel like you can’t breathe

2. Persistent pain or pressure in the chest

3. New confusion or you can’t get up

4. Purplish lips or face

Disclaimer

This survey is to help you report your symptoms of suspected Coronavirus COVID-19. It is not intended to diagnose or treat disease. The Health Ministry will reach out to you based on your perceived risk. This survey is intended only for use for people currently in State Government.

This project was made possible by a collaboration between State Government and Techbarn. State Government’s collaboration with a non-governmental organization does not imply an endorsement of any one particular service, product, or enterprise.

Get medical attention if:

Disclaimer

Do you have a fever? *

Do you have a cough? *

Do you have a sore throat? *

Are you experiencing shortness of breath? *

Have you been around someone who traveled outside the country in the past 4 weeks? *

Have you been around someone diagnosed with Coronavirus COVID-19? *

Please describe any other symptoms you may be feeling

Have you travelled out of state recently? *

Medical history

Personal Information

Get medical attention if:

Disclaimer

Do you have a fever? *

Do you have a cough? *

Do you have a sore throat? *

Are you experiencing shortness of breath? *

Have you been around someone who traveled outside the country in the past 4 weeks? *

Have you been around someone diagnosed with Coronavirus COVID-19? *

Please describe any other symptoms you may be feeling

Have you travelled out of state recently? *

Departure

Transit Arrival (Optional)

Transit Departure (Optional)

Arrival

Medical history

Personal Information