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Your health and safety
For your health and safety, please complete the form below daily, before entering our location.
All information will be kept confidential
Company Name (if visitor):
Ximedica Sponsor (if visitor):
Have you had any of the following symptoms in the past 3 days that are not explained by allergies or a non-infectious cause?
Shortness of breath / Difficulty breathing:
Muscle Pain or Body Aches:
Runny nose / Stuffy nose:
Nausea or Vomiting:
Loss of smell / Loss of taste:
Have you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days?
Have you traveled anywhere outside the 50 United States in the past 14 days?
If you have traveled outside the US in the last 14 days, Have you been tested for COVID19 in the last 72 hours and received a negative result? (
Proof of results will be required
Have you traveled to Rhode Island for a non-work-related purpose from another city, town, county, or state that currently has a stay-at-home restriction, a shelter-in-place restriction, or a similar restriction, declaration, or announcement due to a COVID-19 outbreak? (see list maintained by the Rhode Island Department of Health (RIDOH) at
Have you traveled to Rhode Island from one of the states listed
with a positivity rate of COVID-19 greater than 5%?
If so, you are required to quarantine for 14 days after arrival while in Rhode Island. As an exception, you may provide proof of a negative test for COVID-19 that was taken within 72 hours
in Rhode Island. If you receive a test
during your quarantine
in Rhode Island and get a negative test result, you can stop quarantining. However, you still need to self-monitor for
of COVID-19 for 14 days after arrival, wear a mask in public, and follow physical distancing guidelines. You also must quarantine while waiting for a negative test result.
If you’ve recently arrived in Rhode Island from outside the 50 states or DC or from a
within the 50 states or DC, you do not need to quarantine if:
You’ve received a final dose of a COVID-19 vaccine at least 14 days before your last exposure or out-of-state travel that is either FDA approved or received an Emergency Use Authorization (EUA) and
It’s been less than 90 days since your final vaccine dose and
You haven’t had symptoms of COVID-19 since your last exposure or out-of-state travel.
Always watch for symptoms for a full 14 days after travel. If you have
symptoms of COVID-19
at home and
. Vaccinated travelers should still get a COVID-19 test between 5 and 10 days after out-of-state travel. Learn more about the COVID-19 vaccine.
Additional testing sites:
Have you been directed to quarantine or isolate by the Rhode Island Department of Health or a healthcare provider in the past 14 days? If so, when does/did your quarantine or isolation period end?
If yes, when did Quarantine end (Date):
You are permitted in the facility
Please remember to keep social distancing rules and wear a face mask while in the building
I have indicated that I have traveled outside of the US and have tested negative for COVID-19. I may need to show the test result upon entering.
Sorry, you are not permitted in the facility
One or more of the symptoms you selected prevents you from entering the facility. Please stay home