Revised04/22/2020
Fingerprinting COVID-19 Pre-Screening
(Fingerprinting will only be conducted by appointment on Tuesday, Wednesday, & Thursdays from 9am-4pm)
Name__________________________ DOB_____________ Phone #_________________
Address_________________________City___________State___________Zip___________
Incident# _______________________
Travel History
1. In the past 14 days, have you traveled outside the United States? ___Yes ___No
When_________Where_________________________________
2. Does applicant report a history of traveling to or from Europe or Asia ___Yes____No
3. In the past 14 days, have you traveled to any of the following states
(Connecticut, New Jersey, New York, Washington, California, Louisiana)? ___Yes ___No
When_________Where_________________________________
Contact History
4. In the past 14 days, have you had close contact with anyone known to have
traveled to a known COVID-19 area in Europe or Asia? ____Yes____No
5. In the past 14 days, have you had close contact with anyone known to have
traveled to a known COVID-19 area in the United States? ____Yes____No
6. Have you or anyone you’ve been in contact with had a laboratory confirmed
COVID-19 test? (The incubation period is 2-14 days) ____Yes____No
7. Do you currently have a fever, cough, shortness of breath, or other symptoms of lower
respiratory illness? ____Yes____No
Additional Information (Forehead Temperature):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
*If you currently have symptoms (fever, cough, shortness of breath, or difficulty breathing) you will not be approved to receive
fingerprinting services from the Yukon PD.
*In order to receive fingerprinting services, you will be required to wear a face covering as approved by the CDC before
entering the police department and during the finger printing process. You will also be required to wash your hands with soap
and water prior and after fingerprinting.
Requester Name and Signature______________________________________Date & Time________________________
Reviewer Name and ID #______________________________________ _____Date & Time________________________
