COVID 19 Health Screening
Please respond to this screening checklist every time you report to a senior center activity. This questionnaire is NOT intended to take the place of medical advice, diagnosis, or treatment. If you should answer YES to any of the questions included on this checklist, please contact Lori Wells, Senior Center Manager, before participating.

Please keep in mind the following:
All participants MUST be senior center members. Call 231-922-4911 to verify if necessary.
All participants MUST have a signed COVID waiver on file. Waiver is available on website.
If there is a fee for the senior center activity - come with correct change to minimize contact.
If you don't feel well, please stay home.
Please bring your own equipment for all activities. Senior Center equipment may not be available for public use.
Dress for the weather. Indoor accommodations are not available at this time.
Outdoor restrooms are available on the southeast end of the Senior Center.
Please bring your own water bottle as drinking fountains have been turned off.
All participants are asked to maintain physical distancing of six feet or more from all non-household members.
Wash your hands frequently, or bring hand sanitizer for your personal use.

Your e-mail address will be recorded when you submit this form.
Email address *
First and Last Name: *
Telephone Number *
What activity are you participating in within the next 24 hours? *
In the past 24 hours have you had:
If you answer yes to any of the following questions, we ask that you not enter our building.
Have you recently had any of the following symptoms: Fever, worsening cough, atypical shortness of breath, vomiting or diarrhea, sore throat, chills, muscle pain, headache, or loss of smell or fever over 100.4? *
In the past 14 days, have you had close contact (within approximately six (6) feet for a prolonged period of time) with an individual diagnosed with COVID-19? *
In the past 14 days, have you traveled via airplane internationally or domestically? *
Have you been directed or told by the local health department or your healthcare provider to self-isolate or self-quarantine? *
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Grand Traverse County. Report Abuse