Health Questionnaire for SMAA Building Access

Date *

First Name *

Last Name *

PLEASE READ EACH QUESTION CAREFULLY AND ANSWER YES OR NO TO EACH QUESTION.

Have you or your child experienced any of the following in the past 48 hours: • Fever or chills • Cough • Shortness of breath or difficulty breathing • Fatigue • Headache • New loss of taste or smell • Sore throat • Congestion or runny nose • Diarrhea? YES or NO *

Within the past 14 days, have you or your child been in close physical contact (6 feet or Closer) for a Cumulative total of 15 minutes with: • Anyone who is known to have laboratory-confirmed COVID-19? OR • Anyone who has any symptoms consistent with COVID-19? YES or NO *

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? YES or NO *

Are you or your child currently waiting on the results of a COVID-19 test? YES or NO *

I hereby certify that the responses provided above are true and accurate to the best of my knowledge. TYPE YOUR NAME BELOW TO CERTIFY YOUR ANSWERS. *

NO answer to all questions –Access to Church facilities is APPROVED. YES answer to ANY question—Access to Church facilities in NOT APPROVED. You may be at increased risk for COVID-19 and should call your primary care provider for further instructions including information about COVID-19 testing. If you are member of the staff, you should also contact your supervisor. *

I have answered NO to all questions and I will enter the building.
I have answered YES to one or more questions and I will NOT enter the building.

Phone

Please answer these questions before entering the building. If you answer YES to any of them, please do not enter and contact your supervisor.