Dear Parishioner/Guest: 
 
In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our clergy, parishioners, guests and yourself, please be truthful and candid in your answers. 
 
By completing this questionnaire and signing my name below, I agree to make St. Luke’s Episcopal Church aware of any positive COVID-19 test and/or exposure (defined as close contact <6ft for more than 15min with a COVID-19 positive individual or person suspected of COVID-19 in period of 2 days prior to their symptom onset) within 1wk of diagnosis. This will allow appropriate measures be taken to maintain the safety of our parish and its parishioners through contact tracing. 
 
PRINTED NAME OF PARISHIONER/GUEST: (Remember to complete one per family member) 
 
____________________________________________ 
 
HOME ADDRESS: 
______________________________________________________________________________ 
 
______________________________________________________________________________ 
 
PHONE CONTACT:  	 	 	 	EMAIL: 
 
(________)______________________ 	 	 	________________________________ 

SIGNATURE: _____________________________________________ DATE: ____/____/______ 

ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? 
 ______ YES ______ NO 
 
HAVE YOU HAD ANY RECENT CONTACT (WITHIN 14 DAYS) WITH ANYONE 
DIAGNOSED OR SUSPECTED TO HAVE COVID-19?  ______ YES ______ NO 
 
DO YOU HAVE A FEVER? ______ YES ______ NO 
 
DO YOU GET CHILLS OR UNCONTROLLABLE SHIVERING DURING THE DAY OR 
NIGHT? ______ YES ______ NO 
 
DO YOU HAVE ANY SHORTNESS OF BREATH? ______ YES ______ NO 
 
DO YOU HAVE A DRY COUGH? ______ YES ______ NO 
 
DO YOU HAVE A SORE THROAT? ______ YES ______ NO 
 
DO YOU HAVE DIARRHEA OR ANY GI SYMPTOMS? ______ YES ______ NO 
 
DO YOU HAVE A RASH ON YOUR HANDS OR FEET? ______ YES ______ NO 
 
DO YOU HAVE A RUNNY NOSE? ______ YES ______ NO