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Marion COVID-19 Screening

  1. 1. Do you have a fever over 100.4°F?*

  2. 2. Do you have two or more symptoms listed by the CDC for COVID-19?

  3. Myalgia (pain or muscle aches)*

  4. Chills*

  5. Rigors*

  6. Malaise (fatigue, not feeling well)*

  7. Headache*

  8. Sore throat*

  9. Lower respiratory illness (cough, shortness of breath, or difficulty breathing)*

  10. New olfactory (smell) and taste disorders*

  11. Nausea or vomiting*

  12. Diarrhea without an alternate more likely diagnosis*

  13. 3. In the last 14 days have you been in close contact with someone who has or might have COVID-19?*

  14. 4. In the last 14 days, have you traveled anywhere on the quarantine list from the Kansas Department of Health and Environment:?*

  15. Pursuant to Supreme Court Administrative Order 2020-PR-90, a face mask or face covering is required to be worn by everyone in the courtrooms, court offices, and common areas. A mask will be provided by the court if you do not have your own.

  16. I SWEAR OR AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE ABOVE STATEMENTS, REPRESENTATIONS, AND ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

  17. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  18. Electronic Signature

  19. Leave This Blank:

  20. This field is not part of the form submission.