Holy Blossom Temple: Self-Assessment
To prevent the spread of COVID-19, to reduce the potential risk of exposure to our workforce and visitors, and to assist in any future contact-tracing, we thank you in advance for taking the time to fill out this brief self-assessment.
For tradespeople, what company?
I do not have an email address
Purpose of Visit
Time of entry
Time of day
1. Are you currently experiencing any of these symptoms?
ever or chills,n
ew or worsening cough, n
ew or worsening shortness of breath,r
unny nose or nasal congestion, s
ore throat, d
ecrease or loss of sense of taste or smell, n
ew or unexplained nausea, v
bdominal pain, k
nown or diagnosed pneumonia
2. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19. Close physical contact means (a) being less than 2 metres away in the same room, workplace or area for over 15 minutes; (b) living in the same home
In the last 14 days, have you been in close physical contact with a person who either: is currently sick with a new cough, fever or difficulty breathing; and/or returned from outside of Canada in the last 2 weeks.
Have you traveled outside of Canada in the last 14 days.
Have you completed all applicable quarantine and self-isolation requirements?
In order to enter the atrium and attend an indoor service or group program, it is a requirement to be fully vaccinated.
I acknowledge that I have two doses of an approved COVID-19 vaccine and received the second dose at least two weeks ago
Physical distancing and proper mask wearing is all of our responsibility.
I acknowledge it is my responsibility to wear my mask correctly, and maintain physical distance.
certify that the foregoing information is true to the best of my knowledge.