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COVID-19 Screening Form
COVID-19 Screening Form
COVID-19 Screening Form
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To prevent the spread of COVID-19 and reduce the potential risk of exposure to everyone who enters the building, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time. This is in accordance of recommendation of the New York State Health Department and the Center for Communicable Diseases
Name
*
First
Last
Time In
*
:
HH
MM
AM
PM
Time Out (estimate if not known)
*
:
HH
MM
AM
PM
Place(s) in Building
*
Meeting With
*
Personal Phone Number (mobile/home)
*
Email
*
In the last 14 days have you experienced a fever, chills, unusual fatigue, body aches, muscle aches?
*
Yes
No
In the last 14 days have you experienced a sore throat, runny nose, cough, or shortness of breath?
*
Yes
No
In the last 14 days have you experienced abdominal pain, vomiting or diarrhea?
*
Yes
No
In the last 14 days have you experienced change in your sense of smell or taste?
*
Yes
No
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
*
Yes
No
In the last 14 days, have you traveled outside of the tri-state area?
*
Yes
No
Where have you traveled to?
Although we are taking all necessary precautions to keep this facility COVID free, we do not recommend that people with underlying conditions that make them more at risk for serious illness spend time in the building at this time. Are you aware of this recommendation and understand it?
*
Yes
No
Consent
*
I understand that by checking this box, I am providing my electronic signature.
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COVID-19 Screening Form
Dear Congregants: The building is closed; please join us for virtual programming.
Click here for more information.
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