Covid Screening for In-Person Activities - Shoreline Covenant Church

Name*

Names of Others in Your Household

If you are completing this form for multiple people in your immediate household, please list their names here.

Event You Are Attending*

e.g. Sunday worship, youth group, committee meeting, etc

Symptom Screen (see list below)*

Yes
No

Have you (or anyone in your household) been ill or had any of the following symptoms in the past 14 days (not attributable to another medical condition)? -fever/chills -cough -shortness of breath/difficulty breathing -fatigue -muscle/body aches -headache -loss of taste or smell -congestion/runny nose -nausea/vomiting -diarrhea

Do you have a fever or have you had a fever in the past 72 hours?*

Yes
No

A fever is defined as any temperature at 100.4 degrees F (38 degrees C) or higher.

In the past 14 days, have you (or anyone in your household) been in close contact with somebody with Covid-19 or with a test pending?*

Yes
No

In the past 14 days, have you (or anyone in your household) had a positive Covid-19 test, or do you have a test pending?*

Yes
No

Have you traveled outside the country in the past 14 days?*

Yes
No