COVID-19 Self Screening Questionnaire

COVID-19 Self Screening Questionnaire

LIFE Church Ministries | 3820 S. Hanover St. | Brooklyn, MD 21225
You must answer “NO” to all the questions in this questionnaire in order to enter 3820 S. Hanover St., Brooklyn, MD 21225. If you answer “YES” to any of the questions, please DO NOT come enter the building.

If you experience any symptoms or answer “YES” to any of these questions, we recommend you to immediately contact your health care provider for recommended next steps. YOU WILL NOT BE ALLOWED TO ENTER THE BUILDING.

1) Have you had any of the following symptoms in the last 24 hours? *

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come to church. You should:(CDC recommendations)
- Self- quarantine for at least 14 days from the date on which you first experienced any of the above symptoms ; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
- Seek medical attention from your healthcare provider.

2) In the last 14 days have you: *

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms ?
Traveled internationally or taken a cruise
Traveled to any COVID-19 restricted states within the USA

If you answered “Yes” to any part of question two, please DO NOT come to church or enter the building. You should self quarantine for at least 14 days, and seek medical attention from your healthcare provider.

I certify to the best of my knowledge; this information is accurate, and I agree that upon entry of LIFE Church Ministries - 3820 S. Hanver St., Brooklyn, MD 21225, I will wear a face mask at all times.
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Date *

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