2022 NEW JERSEY DIOCESE STATE ASSEMBLY
CONTACT TRACING

COVID-19 CONTACT TRACING

This form is used to safeguard everyone involved at 2022 State Assembly. If you are either diagnosed with Coronavirus or experiencing Coronavirus symptoms, please provide us with your contact information. Please also list out the people who you regularly contact or have been in contact with during the last 14-days period for each. If you have been in other public or crowded locations during this period, please specify and also list people that you have contacted. If you are not experiencing symptoms, this form is still used.

First Name

Email Address

Last Name

Date

Address

Emergency Contact

Please select the option that applies to your situation: Have you been fully vaccinated? *

Yes

If you answered "Yes" to the above question, please list the date(s).

Have you been diagnosed with Coronavirus? If "Yes" list the date.

Do you have or show Coronavirus symptoms *

Yes

Have you recently been in another public and/or crowded location? *

Yes

If you answered "Yes" to the above question, if exposed, did you contact an official at this facility to let them know.

Yes

Please list names, addresses and contact information for everyone you have been in contact with in the past 14 days:

We will not, in any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations or individuals, except when applicable by law. • Consistent with CDC Guidelines

I declare that the info I’ve provided is accurate & complete

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DID YOU KNOW?

The origin of The House of God, Which is the Church of the Living God, the Pillar and Ground of the Truth Without Controversy, Inc., Keith Dominion, can be traced to the divine vision of one, Mother Mary Magdalena L. Tate, a unique black woman in American religious history.

In 1903, Mother Tate established the Church as she traveled and preached the Gospel throughout the state of Tennessee.

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"The Lord is my shepherd; I shall not want." Psalm 23:1

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