Request edit access
IBBC COVID-19 Screening Form
PLEASE READ EACH QUESTION CAREFULLY…
Email address *
Name of person attending *
Service Attending. Please select all that you will attend.
If Attending Sunday Am and Pm services this form must be submitted before 9PM on Saturday. If attending Wednesday evening service this form must be submitted before 9PM on Tuesday. Thank you!
1. Have you returned from travel outside the US for the past 14 days?
Clear selection
2. Have you been in any gathering like birthday parties, weddings, funeral, or any other social gatherings for the past 14 days?
Clear selection
3. Have you been diagnosed with COVID-19 in the past 14 days?
Clear selection
4. Have you had a fever in the past 24 hours (100°F)?
Clear selection
5. Have you experienced any of the following symptoms in the past 24 hours?
Clear selection
If yes, please check all that are applicable:
6. Have you taken any of the following medication within 24 hours?
If yes, please check all that are apllicable:
7. Within the past 14 days, have you been in close physical contact (6 ft or closer for a cumulative total of 15 min.) with anyone who is known to have laboratory-confirmed COVID-19?
Clear selection
8. Within the past 14 days, have you been in anyone who has symptoms consistent with COVID-19?
Clear selection
9. Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
Clear selection
10, Are you currently waiting on the results of a COVID-19 test?
Clear selection
If after submitting this form you will not be able to attend due to unforeseen circumstances kindly notify Sis. Theresa Goyeneche via Messenger or through text at 510-862-9570 as soon as possible.
Thank you for completing this form. Please note that a parent or guardian must be the one signing this form for children. By signing your name below, you agree that all information you entered is correct and true, as God is your witness. Thank you & God bless.
Please print your name as an eletronic signature. (Parent or guardian’s signature for children’s forms) *
Today's Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy