FACSDA Screening Questionnaire
This form must be submitted prior to your arrival at the church.
Full Name *
Do you have any of the following Symptoms? *
Fever, Cough, Shortness of Breath, Sore Throat
If you answer Yes to the previous question, please indicate your symptom below:
Is your temperature over 100.4 degrees Fahrenheit? *
Have you, or anyone you have had contact with, traveled outside of the DMV area within the past 14 days to states and countries with sustained community transmission?
Clear selection
In the past 14 days, have you had any contact with anyone with known COVID-19 or who may be under evaluation for exposure to COVID-19 or a person who is ill with respiratory illness? *
In the past 14 days, have you worked in or entered a facility with suspected or confirmed COVID-19 infection? *
If you answered Yes to the previous question, did you wear appropriate PPE?
Clear selection
In the past 14 days, have you taken trips on cruise ships or traveled to another state outside the DC, Metro and Virginia areas? *
Do you have evidence of COVID-19 infection or possible exposure not mentioned before? *
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