Please complete this survey dedicated specifically for COVID-19. Thank you.
YOUR NATION'S ID (If applicable)
YOUR FIRST NAME *
YOUR LAST NAME *
CITY
State
Are you completing this survey for yourself or someone else in your household?
Please identify the household member
NATION'S ID (If applicable)
FIRST NAME
LAST NAME
Relationship to household member
Age Range
Have you or anyone in your household exhibited symptoms consistent with COVID-19? (i.e., fevers, coughing, running nose, sore throat, loss of smell and taste, etc.)
Did you go to the hospital or some other facility to be tested?
Were you tested for COVID-19?
Have you quarantined at home?
What were the results of the test?
Have you quarantined at home?
Have you been hospitalized?
Have you been on a ventilator?
Have you recovered?
Is member deceased due to COVID-19 complications?
Thank you! Your survey has been completed and submitted successfully. Please update this information in the future if there are any changes in status.
Nation's ID
First Name
Last Name
Survey Status
Submit a survey for someone else in your household