FLC Group Meeting Health Check-in
Please fill out a new form every Day you are attending a group meeting at FLC. If you answered "Yes" to any questions, please stay home. Thank you!
* Required
What group are you meeting with? (example: Quilters, MaryUnit, First Lutheran Youth (FLY), etc...)
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Name
*
Your answer
Email address or Phone Number
*
Your answer
Please check participant's temperature. Is anybody's temperature 100.4ºF or higher?
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Yes, temperature is 100.4ºF or above
No, temperature is below 100.4ºF
I do not have a thermometer, Please take my temperature when we arrive
Does anyone in your household have potential symptoms of COVID-19; such as fever, shortness of breath, persistent dry cough, etc. in the 72 hours prior to today?
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Yes
No
Has anyone in the household been diagnosed with COVID-19 within the last 12 days?
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Yes
No
Have you taken any fever reducing medications such as acetaminophen or ibuprofen in the past 24 hours?
*
Yes
No
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