Centennial UMC Volunteer Health Screening
(To be completed on day of activity)

Question Title

* 1. Please Enter your Name and Phone Number

Question Title

* 2. Approximate arrival time

Time

Question Title

* 3. Approximate Departure Time

Time

Question Title

* 4. Have you today or in the last 10 days been diagnosed with COVID-19?

Question Title

* 5. Have you today or in the last 10 days developed a fever or feel feverish?

Question Title

* 6. Have you today or in the last 10 days developed chills

Question Title

* 7. Have you today or in the last 10 days developed a new cough?

Question Title

* 8. Have you today or in the last 10 days developed shortness of breath?

Question Title

* 9. Have you today or in the last 10 days developed a sore throat?

Question Title

* 10. Have you today or in the last 10 days developed new muscle aches?

Question Title

* 11. Have you today or in the last 10 days developed a new headache?

Question Title

* 12. Have you today or in the last 10 days developed a new loss of smell or loss of taste?

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?

0 of 13 answered
 

T