FUCA COVID Heath Screening Questionnaire
Please fill out this form before you enter the FUCA building for any reason. This questionnaire is good for 24 hours UNLESS your health changes in that time.

*If you answer yes to any of the listed symptoms or to having contact with anyone who may have COVID-19 in the last 14 days, please do not enter the building. Contact church staff and your health care provider.

If you have any questions, please contact the church office at 303-421-0891 or the church administrator, Kathy Hine, at 951-204-3638.
Name *
Email address/contact info *
In the last 14 days, have you had any contact (< 6ft for more than 15 min) with anyone who has been diagnosed with COVID-19 or who has been asked to self-isolate/quarantine by their health care provider due to symptoms consistent with COVID-19? *
Are you currently experiencing any of the following symptoms that are not usual for you? Temp of 100.4 F or higher, new loss of smell or taste, shortness of breath or trouble breathing, sore throat, chills, muscle aches or coughing? *
What is your current temperature? *
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