Volunteer Health Screening Centennial UMC Volunteer Health Screening(To be completed on day of activity) Question Title * 1. Please Enter your Name and Phone Number Name Phone Number OK Question Title * 2. Approximate arrival time Date / Time Time AM/PM - AM PM OK Question Title * 3. Approximate Departure Time Date / Time Time AM/PM - AM PM OK Question Title * 4. Have you today or in the last 10 days been diagnosed with COVID-19? No Yes OK Question Title * 5. Have you today or in the last 10 days developed a fever or feel feverish? No Yes OK Question Title * 6. Have you today or in the last 10 days developed chills No Yes OK Question Title * 7. Have you today or in the last 10 days developed a new cough? No Yes OK Question Title * 8. Have you today or in the last 10 days developed shortness of breath? No Yes OK Question Title * 9. Have you today or in the last 10 days developed a sore throat? No Yes OK Question Title * 10. Have you today or in the last 10 days developed new muscle aches? No Yes OK Question Title * 11. Have you today or in the last 10 days developed a new headache? No Yes OK Question Title * 12. Have you today or in the last 10 days developed a new loss of smell or loss of taste? No Yes OK Question Title * 13. Do you agree to notify Centennial UMC in the event that you develop any of the symptoms above or receive a diagnosis of COVID-19 in the next 14 days? Yes No OK DONE