ESCC SERVICE'S SCREENING REGISTER
PLEASE COMPLETE AT HOME BEFORE LEAVING OR BEFORE ENTERING THE BUILDING.
I understand that I must fill a screening form in for ESCC’s record keeping.
I agree to adhere to COVID-19 response strategies that El Shaddai Christian Church & School has put in place to ensure a safe working and schooling environment for all staff and learners.
I will sanitize my hands after screening and before entering the building
I will keep my 2 layer cloth mask on at all times and I will ensure that it covers my nose and mouth at all times. If it does not fit properly, or is not according to the church/ school’s satisfaction, they may issue me with a temporary one.
I will keep a social distance of at least 1,5 m at all times and make no direct contact with any other person besides my own family living in my home.
I will inform a staff member should I start presenting with any of the COVID-19 symptoms during my attendance.
I agree that I enter the premises of El Shaddai Christian Church & School at own risk
* Required
Name
*
Your answer
Surname
*
Your answer
Contact Number
*
Your answer
Spouse Name
Your answer
Child #1 Name
Your answer
Child #2 Name
Your answer
Child #3 Name
Your answer
Child #4 Name
Your answer
Check the boxes that apply to you or any of your family members listed above.
*
Fever / Chils
Cough
Sore Throat
Shortness of Breath
Body Aches
Redness of Eyes
Loss of Smell/Taste
Nausea /Vomiting / Diarrhoea
Fatigue / Weakness
Direct contact, in the last 14 days, with a person infected by the Covid-19 Virus?
No Symptoms
Required
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
