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FACSDA Screening Questionnaire
This form must be submitted prior to your arrival at the church.
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* Indicates required question
Full Name
*
Your answer
Do you have any of the following Symptoms?
*
Fever, Cough, Shortness of Breath, Sore Throat
Yes
No
If you answer Yes to the previous question, please indicate your symptom below:
Your answer
Is your temperature over 100.4 degrees Fahrenheit?
*
Yes
No
Have you, or anyone you have had contact with, traveled outside of the DMV area within the past 14 days to states and countries with sustained community transmission?
*
Yes
No
In the past 14 days, have you had any contact with anyone with known COVID-19 or who may be under evaluation for exposure to COVID-19 or a person who is ill with respiratory illness?
*
Yes
No
In the past 14 days, have you worked in or entered a facility with suspected or confirmed COVID-19 infection?
*
Yes
No
If you answered Yes to the previous question, did you wear appropriate PPE?
Yes
No
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In the past 14 days, have you taken trips on cruise ships or traveled to another state outside the DC, Metro and Virginia areas?
*
Yes
No
Do you have evidence of COVID-19 infection or possible exposure not mentioned before?
*
Yes
No
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