ACEN COVID-19 Daily Self-Certification Form Step 1 of 5 20% 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* Email* 1. Have you had any of the following symptoms in the last seven (7) days?* Yes No Symptoms • Fever or 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. In the last five (5) days, have you tested positive for COVID either by a PCR test or at-home self-test?* Yes No 3. In the last five (5) days, have you come in close contact with someone that tested positive for COVID either by a PCR test or at-home self-test during any of those five (5) days?* Yes No Hidden4. 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 4. In the last five (5) days, have you been directed by a public health official or licensed healthcare provider (e.g., nurse practitioner, physician, physician assistant) to quarantine/isolate due to an exposure to COVID-19 or due to testing positive for COVID by either a PCR test or at-home self-test?* Yes No
