CDC Questionnaire
Name Date
Email
Phone
===================================================================
1. Are you currently experiencing symptoms of COVID-19 which include temperature of 100.4 or
higher, frequent unexplained cough, tiredness, loss of smell and/or taste, shortness of breath or
difficulty breathing, chills, nausea or vomiting, diarrhea?
Yes No
2. In the past 14 days, have you tested positive for or been infected with COVID-19?
Yes No
3. In the past 14 days, have you traveled outside of the District of Columbia/Maryland/Virginia
(DMV) area to any state with a known surge in COVID cases (e.g., Florida, Texas, Georgia,
Louisiana, Arizona, Alabama, South Carolina, Nebraska, or Idaho)?
Yes No
4. In the past 14 days, have you traveled outside of the continental U.S. to another country?
Yes No
5. In the past 14 days, have you been in close contact with any person showing symptoms of, has
been diagnosed with, or is being screened or monitored for COVID-19?
Yes No
=====================================================================================
I acknowledge there is an increased risk that COVID-19 can be transmitted in any place of public
accommodation, including worship service at GBC. I acknowledge that I am assuming such a risk and that
I will follow GBC’s mask requirements.
Please sign
Agree
Disagree
