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)
—Please choose an option—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

—Please choose an option—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

—Please choose an option—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

—Please choose an option—YesNo

OR

Are you experiencing small red or purple spots on your hands and/or feet? (required)
—Please choose an option—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)
—Please choose an option—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)
—Please choose an option—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)
—Please choose an option—YesNo

If you have answered yes to any of the questions, then you will need to refrain from attending the liturgy.
Please make preparations to arrive at the church parking lot a few minutes in advance of your pre-assigned time for entry into the church.
At your assigned time, you will enter through the front doors via the ramp and be greeted by a member of our parishes COVID-19 Guidelines Implementation Committee who will review with you your pre-completed questionnaire. If there are any changes in your answers, you will not be permitted to attend the service. If there are no changes, you will be required to re-sign your questionnaire below prior to being escorted to your preassigned pew.
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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