NWUU COVID-19 Health Screening Questions

Please fill out this COVID-19 Screening before entering the church building. Then check-in with your event coordinator or use the Breeze CHMS app to print your name tag.

Contact Information

Name

This address will receive a confirmation email

Phone

Date and Time

Date of Visit

Time of Arrival

Temperature at Arrival

Screening Questions

1. Have you tested positive for COVID-19 within the last 14 days?

Please select one option.

Yes No

2. In the last 14 days, have you been identified as a close contact of anyone who has had a positive COVID-19 test?

Please select one option.

Yes No

3. To the best of your knowledge, have you been in close proximity to any individual who tested positive for COVID-19, is in quarantine, or is a presumptive positive within the last 14 days?

Please select one option.

Yes No

4. Are you currently experiencing any of the following symptoms: Sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?

Please select one option.

Yes No

5. Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?

Please select one option.

Yes No

If you answer “yes” to any of the above questions, you will be denied entry and you will be provided further instructions.

Description

Please fill out this COVID-19 Screening before entering the church building. Then check-in with your event coordinator or use the Breeze CHMS app to print your name tag.

NWUU COVID-19 Health Screening Questions

Description

Please Fix the Following