Health Screening Questionnaire 健康檢查問卷
For visiting the church campus for worship, a reservation is required and EACH adult or child in your group must complete and pass this health screening questionnaire prior to entering the church facilities.

After submitting your Questionnaire, PLEASE VIEW YOUR SCORE. If you score 10/10, you have passed and we look forward to seeing you on Sunday. You do not need to print the email of your results.

A score 9 and under indicates you may be experiencing symptoms or have been exposed to COVID-19. For your safety, we will be unable to allow you to enter the church campus and we ask that you worship with us at home via livestream.

凡參加橙縣華人浸信會主日聚會者, 每人必需擁有訂座表和健康問卷表，並且您同行人中的每個成年人或孩子都必須填寫並通過這健康檢查問卷，才能進入教堂設備。

提交問卷後，請查看您的分數。如果您的得分為10/10，則表示您已經通過，我們期待在周日見到您。您不需要打印調查結果。

如果您有症狀或曾經與COVID-19患者接觸（分數低於10分），我們將無法讓您進入教堂。我們要求您通過在家現場直播與我們一起敬拜。
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Email *
LAST Name of Attendee 您的姓 *
FIRST Name of Attendee 名字 *
I (Fill your name below) am filling out this questionnaire for my child (under 18 yrs old) or family member in my household as their legal guardian. (if applicable)
父母姓名（如果有）如果您是為18歲以下兒童的父母或法定監護人填寫問卷，請在此處輸入您的姓名
Which Worship Service will you be attending? *
參加以下的主日敬拜
Have you had the onset of the following symptoms in the the last 14 days? *
我聲明在過去14天內，我（或我的孩子）經歷了這些症狀
7 points
Captionless Image
If you have taken a COVID-19 Swab Test, was it Positive or Negative for COVID-19? *
如果您已用過COVID-19拭子測試，結果COVID-19是陽性還是陰性？
1 point
Date of COVID-19 Swab test (if applicable)
COVID-19拭子測試的日期（如果適用）
MM
/
DD
/
YYYY
In the past 14 days, have you been in close contact with anyone who has tested positive? *
在過去的14天裡，您是否與任何測試過陽性的人保持密切聯繫？
1 point
In the past 14 days, have you traveled outside the United States? *
在過去的14天裡，您是否曾在美國以外旅行？
1 point
Disclaimer: In order to minimize the risk of contracting the novel coronavirus (COVID-19), Chinese Baptist Church of Orange County (CBCOC) has established safety measures in accordance with CDC guidelines as set forth by local, state, and federal government authorities. Attendees must adhere to these safety measures set forth in these guidelines along with the CBCOC list of Procedures and accurately answer the pre-registration health questionnaire provided. Since CBCOC is acting in accordance with the local, state, and federal guidelines along with the CBCOC List of Procedures, CBCOC is not liable in the event that a coronavirus outbreak occurs. Your attendance at these services accepts the disclaimer of liability of CBCOC.
免責聲明：為了儘量減少感染新型冠狀病毒（COVID-19）的風險，橙縣華人浸信會（CBCOC）制定了安全措施。這安全措施是 CDC指南制定的並載於地方，州和聯邦政府機關。 參會者必須遵守本指南中規定的安全措施以及CBCOC程序單，並準確回答所提供的註冊前健康調查表。 由於CBCOC依照地方，州和聯邦準則以及CBCOC程序單，因此如果冠狀病毒爆發，CBCOC不承擔任何責任。 您參加這些活動，您同時也接受CBCOC免責聲明。我已閱讀上述的建議，並意識到其中涉及的風險。我們同行的每個人，將會填寫這CBCOC準備的健康問卷,並將其結果印出來。
I have read and acknowledge the disclaimer and will follow the procedures set forth by CBCOC. I acknowledge that I have answered these questions truthfully to the best of my knowledge *
我已閱讀並同意免責聲明。我將遵循CBCOC設定的規則。據我所知，我已經回答了這些問題
0 points
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A copy of your responses will be emailed to the address you provided.
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