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, February 7

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