Volunteer COVID-19 Self Health Screening Questionnaire

Volunteer COVID-19 Self Health Screening Questionnaire
Thank you for choosing to volunteer at Lowcountry Orphan Relief. Please fill out the questionnaire below and return it 24 hours prior to your scheduled date and time.
Please keep in mind, all volunteers will be outside.
1) Have you had any of the following symptoms in the last 24 hours?
Rows Yes No
Sudden loss of taste or smell
Shortness of breath or difficulty breathing
OR at least TWO of the following symptoms in the last 24 hours:
Rows Yes No
Fever (usually 100.4 or higher)
Chills
Cough
Muscle pain or body aches
Headache
Sore throat
Issues breathing or
Sudden Fatigue
If you answered “Yes” to question one, please DO NOT come to volunteer during your date/time. We will be glad to reschedule you at a later date.

2) In the last 14 days have you:

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise?
Or your immediate family members experience any changes to their your/their health?

If you answered “Yes” to any part of question two, please DO NOT come to volunteer during your date/time. We will be glad to reschdule you at a later date.
I certify to the best of my knowledge; this information is accurate.
Signature
Clear
Name
First NameLast Name
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	Yes	No
Sudden loss of taste or smell
Shortness of breath or difficulty breathing