This should be completed before entering a BH facility or going on site. Name* First Last Covid symptoms?*Are you experiencing any Covid-19 symptoms unrelated to known chronic conditions? Fever, Cough, Shortness of Breath, Sore Throat, Headache, Muscle Pain, Chills, Repeated Shaking with Chills, Loss of Taste or Smell.YesNoContact with Covid patient?*Have you had known close contact to a person who is lab-confirmed to have COVID-19 and not yet received your own authorization to return to work by the Department of Health?YesNoAre you currently required to self-quarantine?*Are you currently required to self-quarantine under the NM Quarantine Order effective September 2nd? Link to ordinance. (By answering no, you are attesting that you have read and understand the restrictions)YesNoPassPassNoFailFailNo