COVID-19 Daily Certification Form Step 1 of 8 12% 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* HiddenEmail 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 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 - - - Check all symptoms that apply.* 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 - - - Identify who have or had signs of the following symptoms. Temperature of 100° Fahrenheit or higher* Self Household Member Both Chills* Self Household Member Both Cough* Self Household Member Both Shortness of breath or difficulty breathing* Self Household Member Both Fatigue* Self Household Member Both Muscle or body aches* Self Household Member Both Headache* Self Household Member Both New loss of taste or smell* Self Household Member Both Sore throat* Self Household Member Both Congestion or runny nose* Self Household Member Both Nausea or vomiting* Self Household Member Both Diarrhea* Self Household Member Both 2. Have you or anyone that lives in your household tested positive by an FDA-authorized or FDA-licensed test for COVID-19?* Yes No - - - Identify who has tested positive for COVID-19.* Self Household Member Both - - - Date of test for Self:* MM slash DD slash YYYY - - - Date tested for Household Member:* MM slash DD slash YYYY 3. Have you or anyone that lives in your household 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 - - - Identify who has had close contact with someone that has tested positive for COVID-19.* Self Household Member Both 4. Have you or anyone that lives in your household traveled to an area in the United States that the CDC considers a "hotspot" within the last fourteen (14) days?* Yes No - - - Identify who has traveled to an area in the United States that the CDC considers a "hotspot".* Self Household Member Both 5. Have you or anyone that lives in your household traveled or come in close contact with someone that has traveled outside of the United States the CDC considers a "hotspot" within the last fourteen (14) days)?* Yes No - - - Identify who has traveled or come in close contact with someone that has traveled outside of the United States the CDC considers a "hotspot" within the last fourteen (14) days)?* Self Household Member Both 6. Have you or anyone that lives in your household 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 - - - Identify who has 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.* Self Household Member Both 7. Have you or anyone that lives in your household come in close contact with someone that has 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 - - - Identify who has come in close contact with someone that has 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?* Self Household Member Both
