Screening Questions
This screening tool is intended to help determine if a visitor or member is in good health (e.g., does not have COVID-19) prior to attending an in-person church service. It will also help us keep record of those who attend services, should we need to provide information in the event of community spread of COVID-19.
Today's Date *
Full Name (First and Last) *
Phone Number: *
Do you have a fever (e.g., 37.8 degrees celcius or greater)? *
Please check each box if you DO NOT show the symptom.
I DO NOT have these symptoms: *
Have you travelled in the last 14 days? *
Have you had close contact with anyone that has travelled domestically or internationally in the past 14 days? *
Have you had close contact with anyone with a respiratory illness; a confirmed case (or a case being investigated) of COVID-19? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy