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1. Do you have a fever over 100.4°F?*

Yes
No

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

Myalgia (pain or muscle aches)*

Yes
No

Rigors*

Yes
No

Malaise (fatigue, not feeling well)*

Yes
No

Headache*

Yes
No

Sore throat*

Yes
No

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

Yes
No

New olfactory (smell) and taste disorders*

Yes
No

Nausea or vomiting*

Yes
No

Diarrhea without an alternate more likely diagnosis*

Yes
No

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

Yes
No

If yes, what date were you instructed to quarantine?

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

Yes
No

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.

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.

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.

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Marion COVID-19 Screening