COVID-19 Pre-Screen Questions Hermantown - Centricity Credit Union

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COVID-19 Pre-Screen Questions Hermantown

This form is required to be filled out prior to any in branch appointment.

Name
First Last
Please select all that apply*
- You have not traveled internationally in the last 14 days
- You have not traveled domestically by air in the last 14 days
- You have not traveled on any cruise lines in the last 14 days
- You or any member of your household have not had any flu like symptoms including a fever of 100.4, any respiratory illnesses, or symptoms of COVID-19 in the last 7 days
- You have not had any contact with anyone diagnosed with COVID-19 in the last 14 days
- You are not awaiting the results of a COVID-19 test
- You are not currently isolating or quarantining due to exposure to a person with COVID-19 or with anyone who has symptoms of COVID-19
You will be allowed to make an appointment as long as you meet the following qualifications:
Name
This field is for validation purposes and should be left unchanged.

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