ACEN COVID-19 Daily Self-Certification Form Step 1 of 6 16% HiddenDate Submitting Form: MM slash DD slash YYYY HiddenACEN Office Location* Atlanta Financial Center - 3343 Peachtree Rd NE, Suite 850, Atlanta Lenox Towers - 3390 Peachtree Rd NE, Suite 1400, Atlanta Date to Enter ACEN Office:* MM slash DD slash YYYY First Name* Last Name* Are you ACEN staff?* Yes No ACEN COVID-19 Daily Certification QUICK Form*Are there changes to responses in your most recent form submission? Yes No Email* 1. Have you had any of the following symptoms in the last fourteen (14) days?* Yes No Symptoms • Temperature of 100° Fahrenheit or higher • Chills • Cough • Shortness of breath or difficulty breathing • Fatigue • Muscle or body aches • Headache • New loss of taste or smell • Sore throat • Congestion or runny nose • Nausea or vomiting • Diarrhea 2. Have you tested positive by an FDA-authorized or FDA-licensed test for COVID-19 in the last fourteen (14) days?* Yes No 3. Have you come in close contact with someone that has tested positive by an FDA-authorized or FDA-licensed test for COVID-19 within the last fourteen (14) days?* Yes No 4. Have you traveled outside of the U.S. in a location with a U.S. Department COVID-related travel advisory or CDC travel information within the last 14 calendar days?* Yes No 5. Have you been directed by a public health official or licensed healthcare provider (e.g., nurse practitioner, physician, physician assistant) to self-quarantine due to possible exposure to COVID-19 within the last fourteen (14) days?* Yes No
