COVID-19 Screening – Personas

Funeral for Arnold Itwaru
Covid-19 Pre-Screening Questions

Kindly please fill out the questionnaire below and keep our family and friends safe. Thank you.

Name *

First

Last

Email *

Have you been in contact with anyone that has tested positive for Covid-19 in the past 14 days? *

Yes
No

Are you experiencing any of the following symptoms ; Fever, Cough, Runny Nose, Headache or Loss of Taste? *

Yes
No
Unsure

Have you traveled internationally in the past 14 days? *

Yes
No

Have you received a Covid-19 Vaccine? *

Yes
No
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