COVID-19 Symptom Screening Form

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Please complete this form prior to participating in any on-campus programming.

* First Name

* Last Name

* Email

* Best Phone Number to Contact You

What program do you plan on attending?

* Have you had a fever over 100 degrees in the past 24 hours?

Please Select OneYesNo

* Are you having difficulty breathing or shortness of breath?

Please Select OneYesNo

* Have you recently lost your sense of taste or smell?

Please Select OneYesNo

* Do you or anyone in your household have a positive COVID-19 test result, or positive clinical diagnosis of COVID-19?

Please Select OneYesNo

* Have you had close contact with any person known to be positive for, or clinically diagnosed with, COVID-19 in the last 14 days??

Please Select OneYesNo

* Do you or anyone in your household have a pending COVID-19 test due to illness or exposure?

Please Select OneYesNo

* Do you have nausea, vomiting, or diarrhea?

Please Select OneYesNo

* Do you have a sore throat?

Please Select OneYesNo

* Do you have any unexplained muscle or body aches?

Please Select OneYesNo

* Do you have a new or unexplained headache?

Please Select OneYesNo

* Do you have a new or unexplained cough?

Please Select OneYesNo

* Do you have nasal congestion or a runny nose, not due to other known causes such as allergies?

Please Select OneYesNo

Would you like to make a donation to our COVID-19 Recovery Fund? ($0-$180)

Mon, March 8 2021 24 Adar 5781

Congregation b'nai israel 253 prospect street, northampton, ma 01060 OFFICE@CBINORTHAMPTON.ORG (413) 584-3593