FUCA COVID Heath Screening Questionnaire

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Please fill out this form before you enter the FUCA building for any reason. This questionnaire is good for 24 hours UNLESS your health changes in that time.

*If you answer yes to any of the listed symptoms or to having contact with anyone who may have COVID-19 in the last 14 days, please do not enter the building. Contact church staff and your health care provider.

If you have any questions, please contact the church office at 303-421-0891 or the church administrator, Kathy Hine, at 951-204-3638.

Email address/contact info *

Name *

What is your current temperature? *

Have you been fully vaccinated for COVID-19? (vaccines and 2 wk followup period) *

Yes

Prefer not to answer

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