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Restoration Temple AOG COVID-19 Health Questionnaire
Please complete this form before returning to church. (To be completed for EACH person attending the Service)
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Full Name
*
Your answer
Today's Date
*
MM
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DD
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YYYY
Phone
*
Your answer
Email
*
Your answer
1. Do you currently have a fever of 100.4 degrees or greater? *
*
Yes [No further screening is needed. The attendee cannot be admitted into the building/facility]
No [Go to the next question]
2. Do you have a cough or shortness of breath that began within the past 14 days?
*
Yes [No further screening is needed. The attendee cannot be admitted into the building/facility]
No [Go to the next question]
3. In the past 14 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (Not a blood test)
*
Yes [No further screening is needed. The attendee cannot be admitted into the building/facility]
No [Go to the next question]
4. In the past 14 days, were you notified by your medical provider or he NYC Test and Trace team to remain home because of COVID-19 or did you come in direct contact with someone recently diagnosed with COVID-19?
*
Yes [No further screening is needed. The attendee cannot be admitted into the building/facility]
No [Go to the next question]
5. Within the past 14 days, did you travel outside of the state of New York other than New Jersey or Connecticut?
*
Yes [No further screening is needed. The attendee cannot be admitted into the building/facility]
No [Go to the next question]
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