COVID-19 Self Screening Questionnaire

COVID-19 Self Screening Questionnaire

Highland Church
To do our part in preventing the spread of COVID-19 in our community and workplace, we are restricting access to this facility for anyone who may have recently been exposed to the virus. Please read this carefully.

In the past 24 hours, have you experienced or are you currently displaying any of the following? *

Yes

Fever (usually 100.4 or higher)

Fatigue

Repeated shaking with chills

Muscle Aches and Pains

Persistent Headache

Sore throat

Cough

Sneezing

Diarrhea

If you are experiencing any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps.

2) In the last 14 days have you: *

Yes

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

By signing this document, you are saying that the above information is true and correct.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty: