COVID-19 Self Screening Questionnaire

COVID-19 Self Screening Questionnaire

Volunteers and Guests
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 48 hours, have you experienced or are you currently displaying any of the following? *

Yes

Fever or Chills (usually 99.0 or higher)

Fatigue

Muscle Aches and Pains

Persistent Headache

Sore throat

Cough

Sneezing

Diarrhea

Shortness of breath or difficulty breathing

Recent loss of taste or smell

Congestion

Nausea or vomiting

If you are experiencing any symptoms or answer “YES” to any of these questions, please inform your ministry leader or contact the church at (718) 297-7475. We encourage you to immediately contact your health care professional for recommended next steps. DO NOT physically return to the church until you have received medical documentation from your primary care physician.

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.
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Name *

First Name Last Name
Date *

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Date
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