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COVID-19 Screening Form for St. Mary Great Mother of God Catholic Church
Please complete this form before attending an in-person faith formation class/activity at St. Mary Great Mother of God.
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Full Name
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Your answer
email address
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Your answer
Have you been diagnosed with COVID-19 in the last 14 days?
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Yes
No
Have you come in to close contact (within 6 feet for longer than 15 minutes) with anyone who has been diagnosed with COVID-19?
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Yes
No
Do you have a temperature of 100.4 F or greater?
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Yes
No
Are you currently experiencing COVID-19 symptoms, including fever, cough, sore throat, respiratory illness, shortness of breath, diarrhea, or any other cold/flu symptoms?
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Yes
No
I hereby certify that the all of my responses are accurate to the best of my knowledge.
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Yes, all responses are accurate and correct.
No, the information is not correct.
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