COVID-19 Screening Form

MESSAGE OF HOPE SEVENTH-DAY ADVENTIST

COMMUNITY MISSION

MESSAGE OF HOPE SDA COMMUNITY MISSION

MOH COVID-19 Screening Form

If you are scheduled to be apart of sabbath's service, please complete this form and submit it by 9pm on Friday night.

Name

Date

Do you currently have a cough, fever, shortness of breath or difficulty breathing?

YES NO

Have you had close contact with someone with known or suspected COVID-19 in the last 14 days?

YES NO

Have you had any international, cruise ship, or domestic travel to a location with widespread community transmission within the past 14 days?

YES NO

Have you tested positive or pending for COVID-19 within the past 14 days?

YES NO

Have you had a fever (temperature 100.4 or greater) in the last 48 hours?

YES NO

Have you experienced new loss of taste or smell?

YES NO

Have you experienced vomiting or diarrhea in the last 24 hours?

YES NO

I hereby attest that the information given above is accurate and true.

Agreement

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Communications@mohsda.org

Message of Hope Seventh-Day Adventist

Community Mission