COVID-19 SCREENING QUESTIONNAIRE
In order to prevent the spread of the coronavirus and reduce the potential risk of exposure in the retreat facility, we are asking everyone to complete and submit this questionnaire prior to entering the facility. Please do not enter the facility until your responses have been reviewed and your entry has been approved.  This questionnaire must be submitted prior to arrival to the facility (no exceptions).
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Email *
Last Name *
First Name *
Mobile phone *
Have you or a member of your household had (or continues to have) any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, a temperature at or greater than 100 degrees Fahrenheit?  (If yes, obtain information about who had the symptoms, what the symptoms were, when the symptoms started, when the symptoms stopped.) *
Required
Have you or a member of your household been tested for COVID-19? (If yes, obtain the date of the test, results of the test, whether the person is currently in quarantine, and the status of the person’s symptoms.) *
Required
Have you or a member of your household been advised to be tested for COVID-19 by government officials or healthcare providers? (If yes, obtain information about why the recommendation was made, when the recommendation was made, whether the testing occurred, when any symptoms started and stopped, and the current health status of the person who was advised.) *
Required
Were you or a member of your household advised to self-quarantine for COVID-19 by government officials or healthcare providers? (If yes, obtain information about why the recommendation was made, when the recommendation was made, whether the person quarantined, when any symptoms started and stopped, and the current health status of the person who was advised.) *
Required
Have you or a member of your household traveled outside the U.S. in the past 14 days? (If yes, obtain the city, country, and dates.) *
Required
Have you or a member of your household traveled elsewhere in the U.S. in the past 14 days? (If yes, obtain the city, state, and dates.) *
Required
Do you have any reason to believe you or a member of your household has been exposed to or acquired COVID-19? (If yes, obtain information about the believed source of the potential exposure and any signs that the person acquired the virus.) *
Required
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? Close proximity is defined as being within 6 feet of an infected person for a cumulative total of 15 minutes over a 24 hour period.  (If yes, obtain information about when the contact occurred, what the contact was, how long the people were in contact, and when the diagnosis occurred.) *
Required
I hereby certify that the responses provided above are true and accurate to the best of my knowledge. Note: The information collected on this form will only be used to determine whether you may be infected with COVID-19. The information on this form will be maintained as confidential.  Any questions should be directed to Gina Hinterschied at 614.570.3093  If you have any additional comments please leave them below.
A copy of your responses will be emailed to the address you provided.
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