COVID-19 Screening Form

Service Date: (required)

Service Time: (required)

Name: (required)

Address: (required)

Mobile Phone: (required)

Your Email: (required)

Please indicate if you have a medical exemption from wearing a mask: (required)
---YesNo

Please let us know if you require any special assistance during the service or if you have any issues with mobility, vision, or hearing:

Names of other persons within your "bubble” who will be in attendance (if relevant):

Primary "bubble" contact person name (if relevant):

Primary "bubble" contact person phone (if relevant):

1. Are you experiencing any of the following: (required)

• Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
• Severe chest pain
• Having a very hard time waking up
• Feeling confused
• Losing consciousness

---YesNo

2. Are you experiencing any of the following: (required)

• Mild to moderate shortness of breath
• Inability to lie down because of difficulty breathing
• Chronic health conditions that you are having difficulty managing because of difficulty breathing

---YesNo

3. Are you experiencing 2 or more of the following symptoms (new or worsening)?

• Fever (or signs of a fever such as chills, sweats, muscle aches and lightheadedness)
• Cough
• Headache
• Sore throat
• Painful swallowing
• Runny nose
• Unexplained loss of appetite
• Diarrhea
• Loss of sense of smell or taste

---YesNo

OR

Are you experiencing small red or purple spots on your hands and/or feet? (required)
---YesNo

4. Have you traveled outside of the province of Newfoundland and Labrador within the last 14 days? Travel includes passing through an airport? (required)
---YesNo

5. In the last 14 days, did you have close contact with a person who has been confirmed as having COVID-19? ( Close contact is defined as a person who lives in the same household, or a persons with whom you’ve had close prolonged contact (within 2 meters) while they had symptoms, or to whom you’ve provided care or had direct contact with bodily fluids (e.g. coughed/sneezed on) without appropriate personal protective equipment)? (required)
---YesNo

6. In the last 14 days, did you have close contact with a person who travelled outside of Newfoundland and Labrador who has become ill? (required)
---YesNo

If you have answered yes to any of the questions, then you will need to refrain from attending the liturgy.

NOTE: PLEASE ENSURE YOU USE THE FRONT ENTRANCE WHEN ENTERING AND EXITING SUNDAY SERVICES.

 I confirm that the information given in this form is true, complete and accurate

Please leave this field empty.

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