Contact Information
Name
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State
Zip Code
County
Cell Phone Number
Email Address
example@example.com
Emergency Contact Full Name
Emergency Contact Telephone Number
Contact Demographics
Date of Birth
Age
Sex
Male
Female
Exposure History
1) When was the last time you were at the church?
-
Month
-
Day
Year
2) What building(s) did you enter?
Main Sanctuary Building
Chapel Building
Christian Education Building
3) What room(s) were you in while at church? (Please include all rooms, including restroom)
4) Where did you sit if you attended a service or activity?
5) Were you within 6 feet of anyone at the church for longer than 15 minutes? If yes, date and names of individuals:
6) Did you use any equipment (e.g. microphone, camera, copier, etc.) while you were on the church property?
Yes
No
7) Are you experiencing any COVID-19 symptoms?
Yes
No
If yes, date symptoms began
-
Month
-
Day
Year
8) Signs and symptoms of illness:
9) How do you feel now?
Same as when diagnosed
Improving
Worsening
10) Have you been seen by a health care provider?
Yes
No
Date Seen
-
Month
-
Day
Year
Submit
Should be Empty: