COVID-19 Activity Form

COVID-19 Activity Form

NORTH HILLS COMMUNITY BAPTIST CHURCH
SCREENING FOR COVID-19 EXPOSURE

Please complete this form within 24 hours of the time you are scheduled to serve or meet.

Have you traveled to an At-Risk area in the past 14 days?
YESNO
Please follow the guidance provided by the state here: https://www.health.pa.gov/topics/disease/coronavirus/Pages/Travelers.aspx

Have you been exposed to someone who has been diagnosed with COVID-19 in the past 14 days?
YESNO

Has anyone in your family been sick with a fever, cough, or shortness of breath in the past 14 days?
YESNO

Have you been in an indoor gathering of more than 25 persons or outdoor gathering of more than 50 persons in the past 14 days?
YESNO

Do you have a fever (greater than 100.4 F), difficulty breathing/shortness of breath, new cough, sore throat, headache, muscle aches, chills, or loss of smell or taste?
YESNO

If you have answered YES to any of these questions, please contact the leader who has scheduled you and refrain from serving or attending.

Please understand that you will be required to wear a mask or face covering throughout your time of meeting in person.

Activity Organizer

Meeting/Activity Date

When completing this form online, the information below will be considered your electronic signature.

Participant Name

If a minor, Parent/Guardian

Email