COVID-19 Screening Questionnaire

If you are planning on attending any church programs or meeting in person, please read the following beforehand.

 

In order to open safely, the Avon Park SDA Church will implement a policy of screening members for potential COVID-19 symptoms. Infrared temperature will be checked at the door and members with a temperature greater than 99.9 will be turned away. A brief series of questions will be asked at the door for screening.

 

The following questionnaire is adapted and modified from the American Medical Association COVID-19 screening template. If you can answer yes to any of the following questions, then church leadership requests that you are cleared by a medical professional before attending church or that you stay home to ensure you are less likely to spread COVID-19.

 

  1. Have you or a member of your household had any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever, temperature at or greater than 100 degrees Fahrenheit, nausea, vomiting or diarrhea?

  2. Have you or a member of your household been tested positive for COVID-19?

  3. Have you or a member of your household been advised to be tested for COVID-19 by government officials or healthcare provider?

  4. Were you or a member of your household advised to self-quarantine for COVID-19 by government officials or healthcare providers?

  5. Have you or a member of your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 14 days?

  6. Have you traveled to a known COVID-19 hotspot such as Miami, New York City or Los Angeles in the past 14 days?

  7. Have you or a member of your household traveled outside the US in the past 14 days?

  8. Have you or a member of your household traveled on a cruise ship in the last 14 days?

  9. Have you or a member of your household cared

    for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

  10. Do you have any reason to believe you or a member of your household has been exposed to or acquired COVID-19?

  11. To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?

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