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2. In response to the recent Corornavirus (COVID-19) outbreak and the raised pandemic alert status by the World Health Organizaton (WHO), Montville Township is taking precautions to lessen the spread of the virus. All visitors to Town Hall must have a screening form completed upon entering.
4. First Name
5. Last Name
7. Email Address
9. Do you live in the same household or have had close contact with someone who in the last 14 days has been in isolation for COVID-19 or had a test for COVID-19? *

   1. Yes
   2. No
11. Have you been in close contact with someone who has tested positive for COVID-19 in the last 14 days? *

    1. Yes
    2. No
13. Have you visited any states listed under the Governors 14-day quarantine travel advisory in the past 14 days? *

    1. Yes
    2. No
15. Have you exhibited any of the following symptoms today (or within the last 24 hours) which cannot be better explained by another condition:
17. Fever (at or above 100.4)*

    1. Yes
    2. No
18. Rash appearing anywhere on the body*

    1. Yes
    2. No
20. Diarrhea*

    1. Yes
    2. No
21. Cough*

    1. Yes
    2. No
23. Chills*

    1. Yes
    2. No
24. Muscle Aches or Pain*

    1. Yes
    2. No
26. Unusually Weak/Fatigued*

    1. Yes
    2. No
27. Sore Throat*

    1. Yes
    2. No
29. Repeated Shaking/Shivering*

    1. Yes
    2. No
30. Runny/Congested Nose*

    1. Yes
    2. No
32. Loss of Taste or Smell*

    1. Yes
    2. No
33. Shortness of Breath*

    1. Yes
    2. No
35. Nausea*

    1. Yes
    2. No
37. Have you or anyone in the family (household) experienced any of the above symptoms in the last 14 days?*

    1. Yes
    2. No
39. If you answered YES to any of the above, please explain in full detail:
41. Temperature:*
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field