DB COVID Screening

Please fill out and submit the form before coming to church. You may add additional students from the same household.

Date

Saturday, November 15

First Name

Last Name

Việt Ngữ Class

Other

Have you experienced any of the following symptoms within the past 2 weeks? 🤒 Fever or chills 🤭 Cough 😩 Shortness of breath or difficulty breathing 😪 Fatigue 🤕 Muscle or body aches 🤯 Headache 😷 New loss of taste or smell 😷 Sore throat 🤧 Congestion or runny nose 🤮 Nausea or vomiting 🤢 Diarrhea
YesNo
Have you had any known contact with someone who tested positive for COVID-19 within the past 2 weeks?
YesNo
Have you or anyone in your household tested positive for COVID-19 within the past 2 weeks?
YesNo