City Tabernacle of Seventh-day Adventists COVID-19 Screening Questionnaire

City Tabernacle of Seventh-day Adventists

COVID-19 Screening Questionnaire
Date *

Month Day Year
Date Hour Minutes AM/PM Option
E-mail
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2/Apt #

City State

Zip Code
Phone Number *
In the past 14 days, have you tested positive for COVID-19 using a diagnostic test? *

Yes No
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19? *

Yes No
Have you experienced any of the following symptoms in the past 48 hours: 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? *

Yes No
In the past 14 days, have you traveled internationally, OR visited an area in New York City currently considered to be a COVID hotspot, OR returned from a state identified by New York State as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)? (Visit https://coronavirus.health.ny.gov/covid-19-travel-advisory for applicable states.) *

Yes No
Take your temperature now. Is it currently equal to, or greater than 100.4°F OR have you experienced a fever of 100.4°F or greater within the past 10 days? *

Yes No
Are you currently waiting on the results of a COVID-19 test? *

Yes No
Should be Empty: