COVID-19 Courtesy Screening
For the protection and health considerations of you and our church family, please fill out this form prior to entering St Alexis Church. (One form may be filled out per household)
Email address *
1. Are you (or a member of your household) currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Check all that apply.
NAME (One form may be filled out per household visiting today)
2. In the past 14 days, have you (or a member of your household) been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?
3. In the past 14 days, have you (or a member of your household) been in close proximity to anyone who has tested positive for COVID-19?
Clear selection
4. Have you (or a member of your household) been tested for COVID-19 and are waiting to receive test results?
Clear selection
5. Have you (or a member of your household) have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?
Clear selection
6. In the past 14 days, have you (or a member of your household) been on a commercial flight or traveled outside of Connecticut?
Clear selection
7. In the past 14 days, have you (or a member of your household) been in close proximity to anyone who has been on a commercial flight or traveled outside of Connecticut?
Clear selection
Note:
In the interest of the health and safety of our parish community, if you have any current symptoms or you’ve answered yes to any of these questions we ask that you attend our service via our streaming channel at www.facebook.com/stalexischurch or via Zoom (may request an invitation from Fr Steven).
Please select date for completing questionnaire
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St Alexis Orthodox Church
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