Screening Questions

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Screening Questions

This screening tool is intended to help determine if a visitor or member is in good health (e.g., does not have COVID-19) prior to attending an in-person church service. It will also help us keep record of those who attend services, should we need to provide information in the event of community spread of COVID-19.

Today's Date *

YYYY

Full Name (First and Last) *

Phone Number: *

Do you have a fever (e.g., 37.8 degrees celcius or greater)? *

Yes

Please check each box if you DO NOT show the symptom.

I DO NOT have these symptoms: *

new or worsening cough

shortness of breath

sore throat

runny nose or sneezing

nasal congestion

hoarse voice

difficulty swallowing

new smell or taste disorder(s)

nausea, vomiting, diarrhea, or abdominal pain

unexplained fatigue / malaise

chills

headache

hiccups

Option 14

muscle aches

Required

Have you travelled in the last 14 days? *

Yes

Have you had close contact with anyone that has travelled domestically or internationally in the past 14 days? *

Yes

Have you had close contact with anyone with a respiratory illness; a confirmed case (or a case being investigated) of COVID-19? *

Yes

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