COVID-19 Pre-Screening Assessment

COVID-19 Pre-Screening Assessment
For Evangelistic Center Church Service
ALL VISITOR MUST SANITIZE AND WEAR A MASK UPON ENTRY.
We are required to ask a series of questions and take temperature before entering any location hosting a group gathering of 10 or more.
Do you wish to continue? If yes, continue. If no, please processed to the bottom of this form for response.
1) Have you traveled out of the United States, or a state for which a travel advisory has been issued, in the last 14 days?
If Yes, please indicate details of Where and When:
Date
MonthDayYear
Date
2) Have you had any ONE of the following symptoms?
Rows Yes No
NEW Cough
NEW Shortness of breath of difficulty breathing
NEW Sore Throat

OR and TWO of the following symptoms:

Rows	Yes	No
Runny Nose
Nausea / Vomiting / Diarrhea
NEW Fatigue or Malaise
Generalized Muscle Aches and/or pain
NEW Headache
NEW Loss of Taste and/or Smell
Chills / Sweats / Shaking
Fever ( usually 100.0 degree or higher)

3) 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 anyone with flu-like symptoms?
Traveled internationally or taken a cruise
4) OFFICE USE ONLY (Tempature will be taken and recorded by our team upon arrival by our Serve Team Members) What was their tempature at the time of arrival?
If answered “Yes” to any one question or had a fever >100.0 please use the following response:
We apologize but since there was a "Yes" response in this Pre-Screening Assessment and or fever >100.0 we are not allow to let you into the building at this time.
For the safety of others and yourself we recommend you contact your health care provider immediatly.
Thank you for your understanding and cooperation in helping us keep the rest of the attendees and staff safe.
5) Have you tested positive of COVID-19?
If Yes, please enter date of when diagnosed:
MonthDayYear
Date
I certify to the best of my knowledge; this information is accurate.
Name
First NameLast Name
Phone Number
Area CodePhone Number
Email
example@example.com
Date
MonthDayYear
DateHourMinutesAM/PM Option
Refused to participate:
We apologize but it is our responsibility to keep everyone attending service safe as possible. We hope you can understand our position and desire to participate at a later time.
Should be Empty:

Rows	Yes	No
NEW Cough
NEW Shortness of breath of difficulty breathing
NEW Sore Throat

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with anyone with flu-like symptoms?
Traveled internationally or taken a cruise