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If you have traveled out of Indiana within the past 14 days, beyond routine travel, please tell us which cities and states. If not, please respond N/A.
If you have traveled out of the country within the past 14 days, please tell us which countries. If not, please respond N/A.
Have you exhibited fever, cough, shortness of breath in the past 14 days of completing this form?YesNo
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