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Screening Questionnaire and Diagnostic Testing Attestation During COVID-19 Community Transmission To help protect customers and associates during any period of declared COVID-19 community transmission,
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Start by reading the instructions on the screening questionnaire and diagnostic form.
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Fill out all the required fields accurately and honestly.
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If you are unsure about any question, seek clarification from a healthcare professional.
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Double-check your answers before submitting the form.
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Submit the completed questionnaire and diagnostic form to the appropriate healthcare provider.

Who needs screening questionnaire and diagnostic?

01
Anyone who wants to assess their current health status and identify potential risk factors.
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Individuals with a family history of certain medical conditions or those experiencing symptoms that warrant further investigation.
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The screening questionnaire is a series of questions to assess potential risks or symptoms. A diagnostic test is used to confirm a specific condition or disease.
Individuals or organizations required by law or regulation to do so.
Provide accurate information based on personal experiences or observations.
To identify potential risks or symptoms and confirm specific conditions or diseases.
Personal information, medical history, symptoms, and potential risk factors.
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