Name (required) Email Address (required) Phone Number (required) Travel Have you traveled away from your regular living area (many members live in neighboring states and commute into Virginia—that does not count as travel to another state) to another state or outside the country in the past 14 days? YesNo If yes, where did you go? Symptoms Please check Yes or No as to whether you are now experiencing, or have experienced during the past 14 DAYS, ANY of these symptoms a. Fever, feeling hot, or feverish YesNo b. Shortness of breath or difficulty breathing YesNo c. Chills, or repeated shaking with chills YesNo d. Cough YesNo e. Flu-like symptoms, diarrhea, intestinal upset, or fatigue YesNo f. Sore throat YesNo g. Headache YesNo h. Muscle pain YesNo i. Recent loss of taste or smell YesNo Contact Have you come in contact with someone experiencing symptoms of COVID-19 identified above in the past 14 days? YesNo If yes, please explain who you came in contact with, where you came in contact, and why you came in contact with this person. Testing a. I tested positive for COVID-19. YesNo b. I have or had symptoms of COVID-19 and I am waiting for results of COVID-19 testing. YesNo c. If tested for COVID-19, I agree to provide the results of my test to my clergy, DS, and Bishop. YesNo After Event Health Change If I develop 2 or more common symptoms of COVID-19 listed above after attending an In-Person service or gathering, I will immediately contact my local clergy and I will avoid contact with others and seek immediate medical attention. YesNo