Health Screen – 15278 Please enable JavaScript in your browser to complete this form.Full Name *Name of your course *NOLS WFR, EMT, SWR, etc.Course Location *City, State, or name of sponsor organizationCourse End Date *Last day of your courseIndicate any Signs or Symptoms in the list below you have experienced in the 14 days since the last day of your course. If you have had no Signs or Symptoms, select "None of the above". *Coughing, sneezingShortness of breath or difficulty breathingFever or chillsHeadacheMuscle or body achesSore throatNew loss of smell or tasteCongestion or runny noseNausea or vomitingDiarrheaConfirmed or suspected as having COVID-19None of the abovePick at least one. You may select more than one answer.Signature *Clear SignatureBy signing this form, I acknowledge that I may be contacted by the LL office. I understand that COVID-19 is deemed a reportable case, and any information related to COVID-19 will be relayed to the proper authorities. Once this form is submitted, I will be sent my certification card/s.MessageSubmit