Health Assessment
Eastside  Church is concerned for the safety of our members and visitors. In the interest of ensuring a safe and healthy worship environment, and to comply with NYS guidelines, we ask everyone to have their temperature taken and to answer the following questions prior to attending worship at our facility. Answers may be written or verbal, and will be documented by an Eastside staff member(s). The only exception to this requirement are first responders (Police, Fire Department, EMS) with proper identification.

We respectfully ask that anyone who answers YES to any of the 5 questions refrain from entering the building until 2 weeks have elapsed after symptoms have cleared.

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Email *
Full Name *
Date *
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1. Are you currently experiencing any of the following symptoms    (fever, dry cough, fatigue, sore throat, shortness of breath, recent upset stomach or diarrhea, loss of sense of taste or smell, etc.)? *
2. In the last two weeks, have you developed a new cough (not related to allergies or smoking)? *
3. Have you had close contact (6 feet, 2 meters), for 10+ minutes, with a person who has been diagnosed with COVID-19 (coronavirus) within the last 14 days? *
4. Have you travelled via commercial air in the past 14 days? *
5. Do you have a temperature above 99F?   (Please allow staff member to confirm  with non contact measurement) *
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