FJC Health Screening Questionnaire
As part of the sign-up process for any of our services, whether indoors or outdoors, this form must be completed prior to joining the service. The completed list will be available to service leaders and you may be turned away if you have not completed this form.
Email address *
Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath within the past 10 days? *
In the past 10 days, have you gotten a positive result from a COVID-19 test that tested saliva or use a nose or throat swab (not a blood test) that was your first positive result OR was AFTER 90 days from your previous diagnosis date? Please note that 10 days is measured from the day you were tested, not from the day when you got the result. *
Are you considered fully vaccinated against COVID-19 by CDC guidelines OR were you recently (within the past three months) diagnosed with COVID-19 and finished isolation in the past 90 days AND you have not traveled internationally in the past 10 days? Please note that in order to be considered fully vaccinated by CDC guidelines, two weeks must have passed since you received the second does in a two-dose series or two weeks must have passed since you received a single dose vaccine.
Clear selection
To the best of your knowledge, in the past 10 days, have you been in close contact (within 6 feet for at least 10 minutes over a 24 hour period) with anyone who tested positive for COVID-19 or who has had symptoms of COVID-19? Clinical staff who were in appropriate PPE are not considered close contacts in these scenarios. *
In the past 10 days, have you returned from an international destination or a US state or territory other than NJ, PA, CT, MA or VT? *
A copy of your responses will be emailed to the address you provided.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy