BUMC Firewood Ministry Participant Health Survey

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Thank you for volunteering with BUMC's Firewood Ministry! This form must be completed by any volunteer coming on-site to participate in Boone UMC's Firewood activities prior to each scheduled workday. Name and contact info will be used for contract tracing purposes only.

Email *

Name

Phone Number

Emergency Contact Name & Phone Number

I understand that if I feel sick or unwell, I should stay home. *

Yes

Have you been tested for COVID-19 and are awaiting to receive test results?

Yes

Clear selection

If yes, please explain reason for testing

Are you currently experiencing, or have your experienced in the past 14 days, any of the following symptoms? (please take your temperature before you answer these question) *

Fever of greater than 100.7

New cough that cannot be attributed to other conditions

New shortness of breath that cannot be attributed to other conditions

New loss of taste or smell

Chills

None of the above

Required

Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days or been asked by the health department or other health care providers to quarantine? *

Yes

Is there anything else you feel we need to know that was not asked above?

Submit

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