SWCRC Meeting/Event Screening Form

To prevent the spread of COVID-19 and reduce the potential risk of exposure, the SWCRC is required to ask all in-person meeting and event attendees to complete the following health screening form. Thank you for your support and partnership to protect our membership and the entire community.

SWCRC Meeting/Event Screening Form

Name*
First Last
Phone*
Date*
MM slash DD slash YYYY
What event are you attending?*
Health Screening Questions
Are you currently suffering from any of the following symptoms – fever of 100.4 degrees or greater, cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, new loss of smell or taste, and/or gastrointestinal problems, including nausea, diarrhea, and vomiting?*
- Yes
- No
Have you lived with, or had close contact with, someone in the last 14 days diagnosed with or displaying the symptoms of COVID-19?*
- Yes
- No
Have you tested positive for COVID-19 over the last 14 days, and have not been medically cleared?*
- Yes
- No