加略山證道浸信會3月28日會友會 CLBC Members Meeting: March 28, 2021

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Email *

I give permission to CLBC to collect and retain the information I share on this form, and share with Public Health for contact tracing purpose. 本人同意加略山證道浸信會收集及保留此表格內之個人資料，並可提供給公共衛生機構以作追蹤之用途。 *

Your Full Name 姓名 *

Your contact number 聯絡電話 *

1. Do you have any of the signs or symptoms of COVID-19? 你有下列任何新型冠狀病毒之症狀嗎？ *

Fever (37.8 °C or greater) 發燒 (37.8 °C 或以上)

New or worsening cough 剛開始或惡化的咳嗽

Shortness of breath or difficulty breathing 氣喘或呼吸困難

Sore throat 喉嚨痛

Loss of sense of smell or taste 失去嗅覺或味覺

Difficulty swallowing, nausea/vomiting, diarrhea, abdominal pain 吞嚥困難，噁心/嘔吐，腹瀉，腹痛

Runny or stuffy nose (not related to allergies) 流鼻涕或鼻塞（與過敏無關）

Feeling unusually fatigued or tired, any unusual muscle aches 感覺異常疲累或疲倦，任何異常的肌肉疼痛

Chills, headaches 發冷，頭痛

Pink eye 紅眼

None of the above 沒有以上症狀

Required

If answered YES to any of the above, please hold off on coming to church and stay home until well. 如果對以上任何一項的答案為＂是＂，請留在家中直至康復

2. Have you been tested for COVID-19 in the past 14 days? 在過去十四天內, 曾否接受新型冠狀病毒檢測 *

If tested for Covid-19, what is the result? 若曾接受檢測，結果是什麼？

Positive or Pending. Please hold off on coming to church and follow Public Health instructions. 陽性或等候結果，請暫停到教會，並遵從公共衛生指示

Negative 陰性

Clear selection

3. Have you been travelling outside of Canada in the past 14 days? Have you had close contact with someone who are tested positive for COVID-19? 在過去十四天內有否到加拿大以外的地方旅遊？曾否與新型冠狀病毒確診者密切接觸？ *

Yes. Please hold off on coming to church. Please follow Public Health instructions. 有。請暫停到教會，並遵從公共衛生指引

No 沒有

4. If you are instructed by Public Health to self-isolate, have you completed the 14-day quarantine period by the date of members meeting? 如公共衛生指示要自我隔離, 在會友會當天你是否已經完成14天自我隔離？ *

Yes. By then, I will have completed the 14 days self-isolation period. 是。屆時已經完成14天自我隔離.

Not applicable. I did not receive self-isolation instructions. 不適用，我不需要自我隔離。

No, I have not completed the 14 days isolation period. Please hold off on coming to church until 14 days period ends and follow public health instructions. 我還沒有完成14天自我隔離, 請暫停到教會，並遵從公共衛生指引.

If you pass the self-screening, please wear a face mask/face covering and maintain 6 ft physical distancing while on church premises, including chapel, hallways, parking lot etc. Do you need a face mask provided by church? 如果通過自行測試，請於出席聚會時, 在教會走廊及停車場時, 戴上口罩或面罩，並保持6呎社交距離。你需要教會提供口罩嗎？

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