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<!DOCTYPE html>
<html >
<head>
<!-- Site made with Mobirise Website Builder v4.12.3, https://mobirise.com -->
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="generator" content="Mobirise v4.12.3, mobirise.com">
<meta name="twitter:card" content="summary_large_image"/>
<meta name="twitter:image:src" content="assets/images/coronavirus-screening-meta.jpg">
<meta property="og:image" content="assets/images/coronavirus-screening-meta.jpg">
<meta name="twitter:title" content="Coronavirus Self Screening Form">
<meta name="viewport" content="width=device-width, initial-scale=1, minimum-scale=1">
<link rel="shortcut icon" href="assets/images/favicon-128x128.png" type="image/x-icon">
<meta name="description" content="Adder has compiled this COVID-19 Self-Screening form using CDC's recommendations for test kit distribution. ">
<title>Coronavirus Self Screening Form</title>
<link rel="stylesheet" href="assets/web/assets/mobirise-icons/mobirise-icons.css">
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap.min.css">
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap-grid.min.css">
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap-reboot.min.css">
<link rel="stylesheet" href="assets/facebook-plugin/style.css">
<link rel="stylesheet" href="assets/tether/tether.min.css">
<link rel="stylesheet" href="assets/animatecss/animate.min.css">
<link rel="stylesheet" href="assets/dropdown/css/style.css">
<link rel="stylesheet" href="assets/theme/css/style.css">
<link rel="preload" as="style" href="assets/mobirise/css/mbr-additional.css"><link rel="stylesheet" href="assets/mobirise/css/mbr-additional.css" type="text/css">
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new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],
j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src=
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</head>
<body>
<!-- Analytics -->
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new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],
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})(window,document,'script','dataLayer','GTM-W7G7PL4');</script>
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<!-- /Analytics -->
<section class="menu cid-rSi9H6BHgW" once="menu" id="menu2-2g">
<nav class="navbar navbar-expand beta-menu navbar-dropdown align-items-center navbar-fixed-top navbar-toggleable-sm">
<button class="navbar-toggler navbar-toggler-right" type="button" data-toggle="collapse" data-target="#navbarSupportedContent" aria-controls="navbarSupportedContent" aria-expanded="false" aria-label="Toggle navigation">
<div class="hamburger">
<span></span>
<span></span>
<span></span>
<span></span>
</div>
</button>
<div class="menu-logo">
<div class="navbar-brand">
<span class="navbar-logo">
<a href="index.html">
<img src="assets/images/asset-13x2x-361x129.png" alt="Mobirise" title="" style="height: 6.5rem;">
</a>
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</div>
<div class="collapse navbar-collapse" id="navbarSupportedContent">
<ul class="navbar-nav nav-dropdown" data-app-modern-menu="true"><li class="nav-item"><a class="nav-link link text-black display-4" href="stop-coronavirus.html">COVID-19</a></li><li class="nav-item"><a class="nav-link link text-black display-4" href="maps.html">Maps</a></li><li class="nav-item"><a class="nav-link link text-black display-4" href="customers.html">Customers</a></li><li class="nav-item">
<a class="nav-link link text-black display-4" href="analytics.html">Analytics</a>
</li><li class="nav-item"><a class="nav-link link text-black display-4" href="pricing.html">
Pricing<br></a></li>
<li class="nav-item">
<a class="nav-link link text-black display-4" href="https://medium.com/adder-mobile" target="_blank">Blog</a>
</li></ul>
<div class="navbar-buttons mbr-section-btn"><a class="btn btn-sm btn-primary display-4" href="https://portal.adder.io" target="_blank"><span class="mbri-user mbr-iconfont mbr-iconfont-btn"></span>
LOG IN</a></div>
</div>
</nav>
</section>
<section class="engine"><a href="https://mobirise.info/w">html5 templates</a></section><section class="header1 cid-rTs54qSgWM mbr-fullscreen mbr-parallax-background" id="header16-2i">
<div class="mbr-overlay" style="opacity: 0.9; background-color: rgb(255, 255, 255);">
</div>
<div class="container">
<div class="row justify-content-md-center">
<div class="col-md-10 align-center">
<h1 class="mbr-section-title mbr-bold pb-3 mbr-fonts-style display-1">
CORONAVIRUS SELF SCREENING FORM</h1>
<p class="mbr-text pb-3 mbr-fonts-style display-5">After our own team's experience trying to get screened for COVID-19 tests, it's clear that someone needs to help people navigate the process. <br><br>We've put <a href="Standalone COVID-19 Form.html">this screening form</a> together to do that.<br><br>This website is not meant to provide any actionable medical advice, as we are not doctors. We have incorporated the <a href="https://chfs.ky.gov/agencies/dph/pages/covid19.aspx" target="_blank">KY</a> & <a href="https://www.cdc.gov/coronavirus/2019-ncov/index.html" target="_blank">CDC</a> guidelines into a <a href="assets/files/Adder%20-%20HIPAA%20Compliance%20Business%20Associate%20Agreement.pdf">HIPAA-compliant screening form</a> and will only share this data with government health agencies trying to distribute test kits.</p>
</div>
</div>
</div>
</section>
<div id="custom-html-2h"><!-- Type valid HTML here -->
<div>
<script type="text/javascript" src="https://form.jotform.com/jsform/200757853539061"></script>
</div></div>
<script src="assets/web/assets/jquery/jquery.min.js"></script>
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<script src="https://apis.google.com/js/plusone.js"></script>
<script src="assets/facebook-plugin/facebook-script.js"></script>
<script src="assets/smoothscroll/smooth-scroll.js"></script>
<script src="assets/web/assets/cookies-alert-plugin/cookies-alert-core.js"></script>
<script src="assets/web/assets/cookies-alert-plugin/cookies-alert-script.js"></script>
<script src="assets/tether/tether.min.js"></script>
<script src="assets/touchswipe/jquery.touch-swipe.min.js"></script>
<script src="assets/viewportchecker/jquery.viewportchecker.js"></script>
<script src="assets/parallax/jarallax.min.js"></script>
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<script src="assets/theme/js/script.js"></script>
<!-- Google Tag Manager (noscript) -->
<noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-W7G7PL4"
height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript>
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<input name="cookieData" type="hidden" data-cookie-customDialogSelector='null' data-cookie-colorText='#252525' data-cookie-colorBg='rgba(32, 228, 126, 0.5)' data-cookie-textButton='Agree' data-cookie-colorButton='#333333' data-cookie-colorLink='#424a4d' data-cookie-underlineLink='true' data-cookie-text="We use cookies to give you the best experience.">
<input name="animation" type="hidden">
</body>
</html>