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St. George Episcopal Church Pre-Screening/Worship Reservation Form
Ensuring the safety of the community is one of the highest priorities of St. George Episcopal Church. The Church follows CDC guidelines and HIPAA requirements when collecting private health information, which is legally permissible according to the Notification of Enforcement Discretion for Business Associates and HIPAA issued by the US Department of Health and Human Services. The SGEC Vestry and Staff will use up-to-date data, decision trees, and protocols based on guidelines from the CDC, the Episcopal Diocese of West Texas, along with medical expert recommendations, and epidemiology. The range of possible responses depends upon the situation. Strict compliance with isolation, quarantine, and clearance criteria are expected.
Are you submitting for just yourself or your family?
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Myself
My Family
Your Name
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First Name
Last Name
How many in your family (including yourself)
*
Which worship service are you attending?
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10:00 AM Sunday
Other
Email (for pre-screening certificate)
*
example@example.com
Have you, or anyone in your household, been diagnosed with COVID-19 in the last 14 days?
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Yes
No
Please Explain
Do you or anyone in your household have any COVID-19 test results pending?
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Yes
No
Please Explain
Have you, or anyone in your household, experienced any of the following signs/symptoms in the last 48 hours:
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Fever/chills
Cough, shortness of breath, or difficulty breathing
Fatigue, muscle or body aches, or headache
New loss of taste or smell
Sore throat, congestion, or runny nose
Nausea, vomiting, or diarrhea
Fever ≥100°F
I have not experienced any of these signs or symptoms
Please Explain
Have you, or anyone in your household, been in close contact with anyone who has been positively diagnosed with COVID-19 within the last 14 days?
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Yes
No
Please Explain
Do you acknowledge and affirm that your responses in this form are accurate and true, and that you understand and will fully cooperate with SGEC health and safety protocols?
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Yes, I acknowledge and affirm.
No
Please verify that you are human
*
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Unique Form ID
Please enter the Unique Form ID listed above:
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FromName
Submit
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