Christ Church - Wellness Screener

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As the people of Christ Church, it is our responsibility to care for one another to the utmost of our abilities. That includes making sure we're doing everything we can to prevent the spread of COVID-19.

According to our COVID-19 prevention protocol, no one with a known positive diagnosis or with any of the following symptoms is permitted to be present on the property, indoors or outdoors: fatigue, congestion, runny nose, sneezing, cough, sore throat, fever, chills, muscle/body aches, headache, new loss of taste or smell, shortness of breath, difficulty breathing, nausea, vomiting, diarrhea.

Please complete this brief questionnaire BEFORE visiting the Christ Church Detroit Campus. This information is required to support our safe use of our buildings and any contact tracing efforts that may be needed.
If you are completing on behalf of MINOR children, please provide the best way to reach you, and enter the child's name.
If you have any concerns about completing this questionnaire or are unable to complete it prior to visiting the church, you must let Rev. Emily, Rector or Sarah Tribelhorn, Associate for Operations, know in advance.

Email *

Full Name *

Best Phone Number to Reach You *

Date of Your Planned Visit *

YYYY

Time of Your Planned Visit *

Time

Christ Church Building(s) you expect to enter (please check all that apply): *

Sanctuary (includes Columbarium, Vesting Room, Choir Room, & Sacristy)

Atrium (Restrooms)

Ledyard Hall and/or Kitchen

Cary Lounge

Lower Level (Synagogue, Bike Storage, Classrooms)

Sibley House (all floors)

Basement/Undercroft (Laundry, Cleaning, General Storage, Boiler Rooms)

Exterior Only (Courtyard, Woodbridge Lawn)

Required

In the past 14 days, have you experienced any of the following symptoms? Please check all that apply. *

A new fever (100.4 or higher) or a sense of having a fever?

A new cough that you cannot attribute to another health condition?

New shortness of breath that you cannot attribute to another health condition?

A new sore throat that you cannot attribute to another health condition?

New muscle aches that you cannot attribute to another health condition, or that may have been caused by a specific activity, such as physical exercise?

New respiratory symptoms, such as sore throat, runny nose, nasal congestion, or sneezing that you cannot attribute to another health condition?

New chills or repeated shaking with chills that you cannot attribute to another health condition?

New loss of taste or smell that you cannot attribute to another health condition?

None of the Above

Required

In the last 14 days, have you had close contact with an individual diagnosed with COVID-19, or who has symptoms, or who is awaiting test results? *

Yes

In the last 14 days, have you traveled via airplane internationally or domestically? *

Yes

Have you had a COVID-19 test and are currently awaiting results? *

Yes

Please add any comments or concerns

Submit

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