Participation questionnaire

By registering, you are confirming to the following screening statements and further agree to stay at home and take care of yourself if you are feeling sick on Sunday morning:

  1. You have NOT tested positive for COVID-19, and you are NOT presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms.

  2. You have NOT been tested for COVID-19 and are waiting to receive test results.

  3. You are NOT currently experiencing, and have NOT experienced any of the following symptoms in the last 14 days:
    ☐ Cough
    ☐ Shortness of breath or difficulty breathing
    ☐ Fever of 100.4° F or higher
    ☐ Chills
    ☐ Muscle pain
    ☐ Sore throat
    ☐ New loss of taste or smell
    ☐ Nausea, diarrhea, vomiting

  4. You have NOT, in the past 14 days, been in close contact to anyone who experienced any of the above symptoms or has experienced any of the above symptoms since your contact.

  5. You have NOT, in the past 14 days, been in close contact to anyone who has tested positive for COVID-19.

  6. You have NOT, in the past 14 days, traveled outside of the United States.

  7. You have NOT, in the past 14 days, been in close contact to anyone who has traveled outside of the United States.

Entry Sheet​

 For the questions above, I answer yes to all questions and register.

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住所: 2207 Oahu Avenue, Honolulu, HI 96822  U.S.A.

 

電話:808-973-4335

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