Health Check-in and Attendance

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear families,
This year, as we gather in person, we are using this system to make sure everyone stays safe. Please complete this form before EACH session that you attend. You will choose which event you are attending as part of the form (see description of each event to choose appropriate event.) Since completion of this form is a mandate from the Archdiocese, we will also use this for attendance.

Thank you for your cooperation!
Mrs. Lang

Student(s) last name *

Name/s individual names of attendee/s *

Which session are you attending? *

Monthly Faith Formation Family Session (all Faith Formation families)

Confirmation Session (candidate only sessions)

First Communion Preparation Session (Year 2 First Communion Families only)

Date of event *

YYYY

Temperature Check: Temperature is lower than 100.4 degrees *

Yes

Within the last 10 days, have you been diagnosed with COVID-19 or had a test confirming you have the virus? *

Yes

Within the past 14 days, did you live in the same household as, or did you have close contact with, someone who tested positive for COVID-19 and/or someone who has been in isolation for COVID-19? A close contact is someone who was within 6 feet of a person with COVID-19 for at least 15 cumulative minutes while the case was infectious whether or not face coverings were worn. Please note that a case is considered infectious starting 2 days before developing symptoms or, for asymptomatic cases, 2 days prior to the date of their positive test. *

Yes

Have you had any new symptoms excluding pre-existing/longstanding symptoms and/or symptoms that can be attributed to a diagnosis other than COVID-19 since the last symptom check (see list below)? *

Yes

New Symptom Check since last Faith Formation check

1. Do you have Fever (100.4 F/ 38C or higher) or chills
2. Cough or difficulty breathing
3. Muscle or body aches
4. Fatigue or head ache
5. New loss of taste or smell
6. Sore throat
7. Congestion or runny nose
8. Nausea or vomiting
9. Diarrhea

Additional information

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Immaculate Heart of Mary Church Belmont. Report Abuse

Forms