Conclave Health Screening Form

Full Name

Firm Name

Cell Number

1. In the past 24 hours, have you had any signs or symptoms of a fever, such as chills, sweats, feeling “feverish,” or having a temperature that is elevated for you or 100.4F or greater?

Yes No

2. Do you have new onset or worsening of any of the following symptoms in the last 48 hours NOT related to allergies:

Cough, shortness of breath, or chest tightness
Sore throat or unexplained loss of taste/smell
Diarrhea, nausea, or vomiting

Yes No

3. In the last 10 days, have you:

been in contact with anyone who has a confirmed COVID-19 diagnosis?
been notified that you may have been exposed to COVID-19?

Yes No

4. If you have any other helpful information or comments, please describe here:

If you answer Yes to any of questions 1-3 above, please remain in, or return to, your hotel room and call/text the American Gem Society Compliance Officer, Janice Brooks, at 702.793.6175 for further instructions. The information you provide in this form will be forwarded to Janice by email but she may not see it immediately – please reach out to Janice as soon as possible so that we can address your symptoms and determine next steps.

April 15-17, 2024 | Austin, TX

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Conclave Health Screening Form

Mission Statement

American Gem Society

Mission Statement

American Gem Society