COVID-19 Questionnaire

1. Regardless of your vaccination status, have you experienced any of the symptoms in the list below in the past 48 hours? IMPORTANT: ANSWER “YES” EVEN IF YOU BELIEVE THE SYMPTOM(S) IS BECAUSE OF SOME OTHER MEDICAL CONDITION (FOR EXAMPLE, ANSWER “YES” IF YOU HAVE A RUNNY NOSE BECAUSE OF ALLERGIES).

fever or chills | cough | shortness of breath of difficulty breathing | fatigue | muscle or body aches | headache | new loss of taste or smell | sore throat | congestion or running nose | nausea or vomiting | diarrhea

[If you answered "YES" access to Emmanuel Temple Pentecostal Church facilities is "NOT APPROVED"]

2. Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?

If you answered "YES" access to Emmanuel Temple Pentecostal Church facilities is "NOT APPROVED"]

3. Have you been in close physical contact in the last 14 days with:

Anyone who is known to have laboratory-confirmed COVID-19? OR Anyone who has any symptoms consistent with COVID-19?

4. Have you traveled in the past 10 days?

[Travel is defined as any trip that is overnight, out of the country, AND with people that are not in your household.]

I CERTIFY THAT MY RESPONSES ARE TRUE AND CORRECT