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COVID-19 Screening Form
COVID-19 Screening Form for CAMBRIDGE SEVENTH-DAY ADVENTIST® CHURCH, ONTARIO
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Email
*
Your email
ClemYour Name
*
Your answer
Your Phone Number
*
Your answer
Church Attendance Date:
*
MM
/
DD
/
YYYY
Please select from list below ONLY if it applies to you as new or worsening onset:
I travelled outside of Canada in the last 14 days.
Someone I am in close contact with tested positive for COVID-19 in the last 14 days.
I have a fever or unusual chills
Unusual Cough or barking cough (croup)
Unusual Shortness of breath
Decrease or loss of taste or smell
Unusual Muscle aches/joint pain
Extreme tiredness
From the check list above, did any apply to you
*
None of the above applies.
1 or more of the above applies.
Required
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