Reporting COVID-19 Symptoms
If you are experiencing symptoms of COVID-19 within 48 hours after attending our worship services and/or you have had a positive test after attending our worship services, please inform us right away with this form below.

NOTE: If you are registering for our worship services or filling out the Health Questionnaire, please go back to: https://www.cbcoc.org/worship-in-person 

Please answer this form as best as you can so we can help prevent the spread of COVID-19 and inform others to take preventive measures for their safety.
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Email *
Last Name *
First Name *
Name of the Parent (if applicable)
If you are a parent or legal guardian filling this out for a child under 18 years old, please put your name here.
Which Worship Service did you attend? *
Date you attended our Worship Service *
MM
/
DD
/
YYYY
Which of the following symptoms are you experiencing? *
Yes
No
Fever or Chills
Coughing
Shortness of Breath or Difficulty Breathing
Fatigue
Muscle or Body Aches
Headache
New loss of taste or smell
Sore Throat
Congestion or Runny Nose
Nausea or Vommiting
Diarrhea
If you have taken a COVID-19 Swab Test, was it Positive or Negative for COVID-19? *
Date of COVID-19 Swab test (if applicable)
MM
/
DD
/
YYYY
Any additional information? (optional)
Thank you for contacting us to help us prevent the spread of COVID-19 *
Required
A copy of your responses will be emailed to the address you provided.
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