Guest Name ____________________________________________________

Dates you plan to be with us_____________________________________

• Have you traveled to any of these locations in the last 14 days?
  • China
  • Iran
  • South Korea
  • Italy
  • Japan
  • New York City
  • New Orleans
• Have you had any of these symptoms in the last 14 days?
  • Fever greater than 100
  • Difficulty breathing
  • Cough
• Within the last 14 days have you had contact with anyone who has shown the above systems or who was confirmed COVID-19?
• Are you currently experiencing fever over 100, difficulty breathing or cough?
• Does your job bring you regularly in contact with the public and if so, have you been working in the last 14 days?
• When in contact with those that you do not live with have you been observing social distancing and wearing a mask?
• While staying with us do you plan to be going out to public places?