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It is important that you disclose to us any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the virus.
DA Office Visitor Self-Certification Form
Do you have, or have you experienced in the last 5 days?
• A fever or above normal temperature?
• Shortness of breath or trouble breathing?
• A runny nose?
• A dry cough?
• New loss or reduction in your sense of taste or smell?
• A sore throat?
• Been in contact with anyone that has tested positive for COVID-19 or has COVID-19 symptoms?
• Traveled OUTSIDE of Colorado within the past 14 days?
• Traveled OUTSIDE the US in the last 14 days?
If you answer yes to any of the previous questions, you will be asked to reschedule your appointment. We encourage you to seek medical guidance.
*FOLLOWING INFORMATION IS REQUIRED
*DA Contact Email Address(completed form will be emailed to DA Contact):
*Visitor's Email Address(completed form will be emailed to you):
*Visitor Name:
*I will be physically present at the following DA office location today:
*Visitor Signature(type in):
Date of electronic signature:
Questions can be directed to your DA Office Representative - by telephone at 720-874-8500.
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