Health Screen 2020 | Brick Church

Name *

First

Last

Email *

Phone *

Do you currently have a temperature of 100° F or greater? *

No. Go to next question.
Yes. No further screening is required. You may not enter the building.

Do you have a cough or shortness of breath that began in the last 14 days? *

No. Go to next question.
Yes. No further screening is required. You may not enter the building.

In the past 14 days, have you gotten a positive result from a COVID-19 test that tested using saliva or used a throat swab (not a blood test)? *

No. Go to next question.
Yes. No further screening is required. You may not enter the building.

In the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone who either tested positive for COVID-19 (not a blood test) or developed symptoms of COVID-19 (fever, cough, or shortness of breath)? *

No. Go to next question.
Yes. No further screening is required. You may not enter the building.

Have you traveled to a noncontiguous state, US territory or CDC level 2 or level 3 country (www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html) in the last 14 days? *

No.
Yes. No further screening is required. You may not enter the building.

By clicking below, you affirm that you do not currently have a temperature of 100 degrees F or greater and have not: • to your knowledge been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or has had symptoms of COVID-19; • tested positive for COVID-19 in the past 14 days; • experienced any symptoms of COVID-19 in the past 14 days; and/or • travelled from a domestic or international location in the past 14 days that requires you to be under quarantine. Additionally, you agree and acknowledge that information regarding the COVID-19 virus and how it is transmitted continues to evolve, and protocols and guidance to reduce the spread of the virus are developing and changing on an ongoing basis. You further understand that the virus may be spread by people in close contact, including by infected people who have no symptoms, and that the Church is a place where, necessarily, members interact and share space, and that there is a risk that the COVID-19 virus could be transmitted. You expressly accept and assume these risks, whether or not caused by the fault or negligence of others. Provide initials below to indicate your understanding of this statement. *