RTAOG Covid-19 Questionnaire
Restoration Temple AOG Covid-19 Questionnaire for In Person Services to be filled by every Family Member Attending
Full Name *
Email Address *
Date of Service you're Attending *
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1. Do you currently have a fever of 100.4 degrees or greater? * *
0 points
2. Do you have a cough or shortness of breath that began within the past 14 days? *
0 points
3. In the past 14 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (Not a blood test) *
0 points
4. In the past 14 days, were you notified by your medical provider or the NYC Test and Trace team to remain home because of COVID-19 or did you come in direct contact with someone recently diagnosed with COVID-19? *
0 points
5. Within the past 14 days, did you travel outside of the state of New York other than New Jersey or Connecticut? *
0 points
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