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Your email address that replies to this questionnaire will be sent to.
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1. HAVE YOU TRAVELED OUTSIDE THE TRI-COUNTY AREA (BROWARD, MIAMI-DADE AND PALM BEACH) IN THE PAST 10 DAYS, EXCEPT TO/FROM TRAVEL TO YOUR HOME OF RECORD. *
This includes travel outside tri-county area (Broward, Miami-Dade and Palm Beach), as well as to other States within continental United States.
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2. ARE YOU CURRENTLY EXPERIENCING - OR HAVE YOU EXPERIENCED IN THE PAST 72 HOURS - ANY OF THE FOLLOWING SYMPTOMS?
a. FEVER (100.4F / 38C using an oral thermometer)
b. CHILLS
c. COUGH
d. SORE THROAT
e. SHORTNESS OF BREATH
f. BODY ACHES
g. LOSS OF SENSE OF SMELL
h. LOSS OF SENSE OF TASTE *
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3. HAVE YOU BEEN IN A GROUP OF MORE THAN 10 PEOPLE OR HAD CLOSE PERSONAL CONTACT, AS DEFINED BELOW, WITH ANYONE WHO IS EXPERIENCING THE SAME SYMPTOMS AS 2A. to 2H. ABOVE IN LAST 10 DAYS?
a. Within 6 feet for more than 15 minutes
b. In a confined space (cab, small room, shared stateroom, berthing proximity, office etc.) *
The 10 days refers to your Planned or Actual date of arrival on AMO Plans campus as given above.
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4. HAVE YOU VISITED ANY MEDICAL FACILITY (INCLUDING IN-PATIENT HOSPITAL CARE, EMERGENCY TREATMENT OR PROCEDURE AT A HOSPITAL, URGENT CARE FACILITY OR OUTPATIENT FACILITY) IN THE LAST 10 DAYS? *
The 10 days refers to your Planned or Actual date of arrival on campus as given above.
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5. HAVE YOU BEEN CARING FOR SOMEONE AT HOME OR BEEN IN CONTACT WITH ANYONE WHO HAS CONTRACTED OR DISPLAYED SYMPTOMS CONSISTENT WITH COVID-19? *
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6. HAVE YOU EVER BEEN SCREENED, DIAGNOSED OR TESTED FOR THE NOVEL CORONAVIRUS (COVID-19), INCLUDING HERE AT AMO PLANS CLINIC? *
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Covid-19 Vaccines
All AMO Plans / STAR Center COVID-19 protocols remain in place and no immediate relaxation is planned, regardless of whether you have been vaccinated for COVID-19. However, in anticipation of future change, we require the following information.
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7. Have you been vaccinated against COVID-19? *
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8. Was it 1 or 2 dose vaccines? *
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8a. Name of 1-dose vaccine? *
Please pick one or add other(s)
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8a. Name of your 2-dose vaccine? *
Please select one or add other(s)
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Please select a date.
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Please select a date.
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This form should be submitted within 24 hours before your planned arrival on campus
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