COVID-19 Daily Certification Form Step 1 of 8 12% Date Submitting Form: Date Format: MM slash DD slash YYYY ACEN Office Location*Atlanta Financial Center - 3343 Peachtree Rd NE, Suite 850, AtlantaLenox Towers - 3390 Peachtree Rd NE, Suite 1400, AtlantaDate to Enter ACEN Office:* Date Format: MM slash DD slash YYYY First Name*Last Name*Email* 1. Have you or any member of your household had any of the following symptoms in the last fourteen (14) days?*YesNo 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*SelfHousehold MemberBothChills*SelfHousehold MemberBothCough*SelfHousehold MemberBothShortness of breath or difficulty breathing*SelfHousehold MemberBothFatigue*SelfHousehold MemberBothMuscle or body aches*SelfHousehold MemberBothHeadache*SelfHousehold MemberBothNew loss of taste or smell*SelfHousehold MemberBothSore throat*SelfHousehold MemberBothCongestion or runny nose*SelfHousehold MemberBothNausea or vomiting*SelfHousehold MemberBothDiarrhea*SelfHousehold MemberBoth 2. Have you or anyone that lives in your household tested positive by an FDA-authorized or FDA-licensed test for COVID-19?*YesNo- - - Identify who has tested positive for COVID-19.*SelfHousehold MemberBoth- - - Date of test for Self:* Date Format: MM slash DD slash YYYY - - - Date tested for Household Member:* Date Format: 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?*YesNo- - - Identify who has had close contact with someone that has tested positive for COVID-19.*SelfHousehold MemberBoth 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?*YesNo- - - Identify who has traveled to an area in the United States that the CDC considers a "hotspot".*SelfHousehold MemberBoth 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)?*YesNo- - - 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)?*SelfHousehold MemberBoth 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?*YesNo- - - 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.*SelfHousehold MemberBoth 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?*YesNo- - - 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?*SelfHousehold MemberBoth
