COVID-19 Screening Questionnaire

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Pride Center of Vermont will be hosting limited outdoor events with reduced attendance in accordance with Vermont State and Local Health recommendations. We ask that any community members attending any of Pride Center of Vermont in-person events complete this form the evening before the event. You will be asked these questions again at the time of the event.

Pride Center of Vermont and its programs are committed to our community's health & safety. We ask that no one attend in-person events if you are sick or symptomatic (with fever, cough, and/or shortness of breath), if you have traveled outside of Vermont within the last 14 days, if you have received a positive COVID-19 test result within the last 14 days, or if you have had contact with any other person who is diagnosed with COVID-19 within the last 14 days. When attending events please be mindful of frequent hand-washing or hand sanitizing, wear a cloth mask or covering (if you do not have one, please reach out to staff and we will provide one for you), and observe physical distancing of 6 feet or more with people that you do not live with.

For more information on COVID-19 prevention, please go to: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/index.html.

We will be collecting names and contact information and of those who attend PCVT sponsored events. We will keep the information for a minimum of 30 days so that we may contact participants in the case of possible exposure to COVID-19. We will not share the identities of any group participants with any agency outside of PCVT. We will not disclose the identities of any individual that tests positive for COVID-19.

Email *

Which event will you be attending? (include date)

Name *

Phone #:

Email *

Have you traveled outside of Vermont in the last 14 days?

Yes

Clear selection

Do you have new or worsening onset of any of the following symptoms: fever, cough, shortness of breath, runny nose, chills, body aches, fatigue, headache, loss of taste/smell, eye drainage, congestion? *

Yes

If "Yes" to above question, please list symptoms. (optional)

Was your temperature over 100.4° F or 38° C today? *

Yes

Have you been exposed to someone being tested for COVlD-19 or who has symptoms compatible with COVID-19? *

Yes

Are any members of your household or a close contact in quarantine for exposure to COVlD-I9? *

Yes

If you answered no to question 1 or yes to any of questions 2-6

Please remain home, contact your health care provider and join our programs virtually.

I have the responsibility to immediately notify the event coordinator should my responses on this questionnaire change. *

I understand

Required

Send me a copy of my responses.

Submit

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