Pre-Lesson Questionnaire

Name

Within the last 24hours have you experienced any of the following? Fever or chills. Cough. Shortness of breath or difficulty breathing. Fatigue. Muscle or body aches. Headache. Nausea or vomiting Diarrhea. New loss of taste or smell. Sore throat.

Within the last 14 days have you been in contact with someone with Covid-19

Within the last 14 days have you been outside MA:

I understand I must bring my learner's permit, driving record to my appointment

I understand Phones, Food, and Drinks are not allowed in the car

I understand my face mask must be worn for the entirety of the time I am in the car