BPC User Health Check Form

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To be filled out ONLY when you enter the office. If you are sick /experiencing any symptoms of cold or flu, please STAY HOME. If you are working from home DO NOT fill out this form. Thermometer is on the sacristy table outside of Carolee's office for your temperature check.

https://www.nj.gov/governor/news/news/562020/20201028a.shtml

Link to NJ pandemic guidelines

NAME

Temperature

Are you experiencing any of the COVID 19 symptoms below? :

Fever or chills

Cough

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 vomiting

Diarrhea

I have been in contact with someone experiencing COVID symptoms

I am under a state mandated quarentine

NONE OF THE ABOVE

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