EACO Covid-19 Screening Form (English)
Please complete screening before attending in-person fellowships, meetings or worship services at church.
One form for each person (age 12+) [version_2204]
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Email *
Name *
Contact phone number *
Intended Date of Attendance *
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1. Do you or anyone in your household have ONE OR MORE of these new or worsening symptoms (not related to other known causes or conditions)? Fever/Chills, Cough, Difficulty Breathing, Decrease/loss of smell and taste *
2. Do you or anyone in your household have TWO OR MORE of these new or worsening symptoms (not related to other known causes or conditions)? Sneezing, Sore throat, Headache, Very tired, Runny/stuffy nose, Muscle aches/Joint pain, Nausea/vomiting/diarrhea *
3.  In the last 14 days, have you travelled outside of Canada AND are required to quarantine per the federal quarantine requirements (only applied to not fully vaccinated travellers)? *
4.  In the last 5 days (10 days if you are not fully vaccinated and 12 years of age and older or if you are immunocompromised), have you or anyone in your household tested positive for COVID-19 on a rapid antigen test or PCR test? *
5.  In the last 5 days (10 days if you are not fully vaccinated and 12 years of age and older or if you are immunocompromised), have you received a COVID Alert exposure notification on your cell phone?            (If you are fully vaccinated, answer "No". ) *
6.  In the last 5 days (10 days if you are not fully vaccinated and 12 years of age and older or if you are immunocompromised), have you been identified as a “close contact (high risk contact)” of someone who has tested positive for COVID-19?  If you are fully vaccinated AND DO NOT live with the person who tested positive or has symptoms, answer "No".  If Public health has advised you that you do not need to self-isolate, answer “No”. *
7.  How many children of age 12 or under are with you today?
IMPORTANT: If the answer to any of the above questions is "Yes", you should stay at home and attend the Worship service online. By agreeing, I acknowledge that:  (1) all information provided above is accurate, (2) I have agreed to follow the protocols and procedures put in place by EACO upon entering the Worship Sanctuary, and (3) I also agree to inform EACO (office@eaco.ca) immediately, if I am later tested or diagnosed COVID-19 positive.  
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