screeningsurvey.com Open in urlscan Pro
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  <div id="app-survey" class="my-1">
    <div id="app-page">
      <div class="">
        <div class="container">
          <div class="row">
            <div class="col-12 col-lg-5 order-lg-2 col-xl-4 pt-3 mx-auto ml-lg-0">
              <div class="card shadow-sm">
                <div class="card-body">
                  <h1 class="h5">Do you need a COVID-19 screening survey to re-open your doors?</h1>
                  <p class="text-center">Take ours to sign up today</p>
                  <p class="text-center small">-or-</p>
                  <p class="text-center"><a href="mailto:covidSurvey@ingenious.org?subject=COVID-19 Screening Survey&amp;body=I would like to sign up for a COVID-19 Screening Survey!" target="_blank" class="btn app-color-btn">Contact Us</a></p>
                </div>
              </div>
            </div>
            <div class="col-12 col-lg-5 col-xl-4 pt-3 mx-auto order-lg-1 mr-lg-0">
              <div class="card shadow-sm">
                <div class="card-body">
                  <p>Please review and complete the form below.</p>
                  <div class="form-group"><label for="inputFirstName">First Name</label><input type="text" class="form-control" id="inputFirstName" aria-describedby="firstNameHelp" placeholder="John" name="form[first_name]" value="" required="">
                    <div class="invalid-feedback">Please enter your first name.</div>
                  </div>
                  <div class="form-group"><label for="inputLastName">Last Name</label><input type="text" class="form-control" id="inputLastName" aria-describedby="lastNameHelp" placeholder="Doe" name="form[last_name]" value="" required="">
                    <div class="invalid-feedback">Please enter your last name.</div>
                  </div>
                  <div class="form-group"><label for="inputPhoneNumber">Phone Number</label><input type="text" data-type="phone" class="form-control " id="inputPhoneNumber" aria-describedby="phoneNumberHelp" placeholder="(716) 555-5555"
                      name="form[phone_number]" value="" required="">
                    <div class="invalid-feedback">Please enter your phone number.</div>
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                  <div class="form-group"><label for="inputEmail">Email Address</label><input type="email" class="form-control " id="inputEmail" aria-describedby="emailHelp" placeholder="username@domain.com" name="form[email]" value="" required="">
                    <div class="invalid-feedback">Please enter your email address.</div>
                  </div>
                  <div class="form-group"><label for="inputSymptomItems">Have you experienced any COVID-19 symptoms in the past 14 days?<br><small class="form-text text-muted">Fever (temperature of 100°F or above) or chills, body aches, cough,
                        shortness of breath, sore throat, nasal congestion, nausea, vomiting, diarrhea, loss of taste and/or smell. Please answer 'yes' only if you are experiencing a new onset of symptoms OR you are experiencing a change in symptoms
                        from your own baseline if you have preexisting medical conditions (e.g. allergies, asthma)</small></label><select class="form-control custom-select" id="inputSymptomItems" name="form[experienced_any_covid_19_symptoms]"
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                      <option value="">-</option>
                      <option value="Yes">Yes</option>
                      <option value="No">No</option>
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                    <div class="invalid-feedback">Please select an option.</div>
                  </div>
                  <div class="form-group"><label for="inputPositiveItems">Have you tested positive for COVID-19 in the past 14 days?</label><select class="form-control custom-select" id="inputPositiveItems" name="form[tested_positive]" required="">
                      <option value="">-</option>
                      <option value="Yes">Yes</option>
                      <option value="No">No</option>
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                    <div class="invalid-feedback">Please select an option.</div>
                  </div>
                  <div class="form-group"><label for="inputContactItems">Have you been in close contact with a confirmed or suspected COVID-19 case in the past 14 days?</label><select class="form-control custom-select" id="inputContactItems"
                      name="form[been_in_close_contact]" required="">
                      <option value="">-</option>
                      <option value="Yes">Yes</option>
                      <option value="No">No</option>
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                    <div class="invalid-feedback">Please select an option.</div>
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                  <div class="form-group">
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                    <div class="invalid-feedback">Please confirm your not a robot.</div>
                    <script src="https://www.google.com/recaptcha/api.js"></script>
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                  <div class="form-group">
                    <div class="btn-group btn-block" role="group"><button type="submit" class="btn btn-secondary app-color-btn" name="form[go]" value="2"><i class="fas fa-arrow-right"></i></button></div>
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                  <div class="form-group">
                    <div class="custom-control custom-checkbox mt-5"><input type="checkbox" class="custom-control-input" id="inputSave" name="form[save]" value="1"><label class="custom-control-label small" for="inputSave">Remember my
                        information.</label></div>
                  </div>
                </div>
              </div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="">
      <div class="container">
        <div class="row">
          <div class="col-12 col-lg-5 pt-3 mx-auto">
            <p class="text-center small text-secondary">© 2022 <a href="https://ingenious.org/" class="text-black">Ingenious, Inc.</a><br><a href="/privacy-policy/" class="text-secondary">Privacy Policy</a></p>
          </div>
        </div>
      </div>
    </div>
  </div>
</form>

Text Content

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COVID-19 Screening Survey


DO YOU NEED A COVID-19 SCREENING SURVEY TO RE-OPEN YOUR DOORS?

Take ours to sign up today

-or-

Contact Us

Please review and complete the form below.

First Name
Please enter your first name.
Last Name
Please enter your last name.
Phone Number
Please enter your phone number.
Email Address
Please enter your email address.
Have you experienced any COVID-19 symptoms in the past 14 days?
Fever (temperature of 100°F or above) or chills, body aches, cough, shortness of
breath, sore throat, nasal congestion, nausea, vomiting, diarrhea, loss of taste
and/or smell. Please answer 'yes' only if you are experiencing a new onset of
symptoms OR you are experiencing a change in symptoms from your own baseline if
you have preexisting medical conditions (e.g. allergies, asthma)-YesNo
Please select an option.
Have you tested positive for COVID-19 in the past 14 days?-YesNo
Please select an option.
Have you been in close contact with a confirmed or suspected COVID-19 case in
the past 14 days?-YesNo
Please select an option.
Please confirm your not a robot.

Remember my information.

© 2022 Ingenious, Inc.
Privacy Policy