Safety & Welfare Check Questionnaire
The Lighthouse SDA Church is taking every necessary precaution to protect our members and visitors.

Please answer the following questions by picking the appropriate response. This information will be entered into the church's secure computer database guided by HIPPA (Health Insurance Portability & Accountability) regulations.

For the safety and welfare of our members and visitors, if you answered YES to any of the
questions, we kindly ask that you leave the premises and inform your healthcare provider.

If you are diagnosed with COVID-19 within the next 14 days, please inform us by calling:
954-583-4062

In compliance with contact tracing, DO NOT LEAVE OR GIVE YOUR NAME.

Thank you for your cooperation.
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First and Last Name *
Phone Number *
Event Attending *
1. Have you tested positive for COVID-19 in the past 14 days or have any reason to believe you have COVID-19? *
2. Do you have reason to believe you have been exposed to COVID-19, or been in close contact with someone who has had a confirmed case of COVID-19 in the past 14 days? *
3. Are you currently experiencing, or have experienced any of the following in the last 14 days? *
Yes
No
Persistent coughing
Difficulty breathing
Sore throat
Loss of taste
Nausea (feeling sick with an urge to vomit)
Vomiting
Nasal congestion (stuffy nose)
Unexplained headache
Diarrhea (frequent liquid stool)
Fever (temperature of 100.4o F)
4. Have you traveled internationally within the past 14 days? *
5. Have you traveled to or from any state or territory identified by federal, state, or local governments as being subject to travel or quarantine advisories due to COVID-19? *
6. To the best of your knowledge, have you had contact with anyone who has traveled internationally within the past 14 days? *
I confirm that the information is correct *
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