COVID-19 Questionnaire

First Name (required)

Last Name (required)

Ministry / Activity
Men’s MinistryWomen’s MinistryLectorsReligious EducationChoirKnights of the AltarKnights of MaryMYOMYAother

Do you have a fever or above normal temperature?
YesNo

Have you experienced shortness of breath or had trouble breathing?
YesNo

Do you have a dry cough?
YesNo

Do you have a runny nose?
YesNo

Have you recently lost or had a reduction in your sense of smell?
YesNo

Do you have a sore throat?
YesNo

Have you been in contact with someone who has tested positive for COVID-19?
YesNo

Have you tested positive for COVID-19?
YesNo

Have you been tested for COVID-19 and are awaiting results?
YesNo

Have you traveled outside of the US in the past 14 days?
YesNo

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed any conditions in my health history which may result in a compromised immune system.

By submitting this document, I acknowledge that the answers I have provided are true and accurate.

Relationship to the member
SelfParentGrandparentGuardianSiblingLegal representative

Name if not the member