Sign In
Forgot Password
or Sign In With
Powered By
ShulCloud
Login
New User:
Register Now
Congregation B'nai Israel
Calendar
events
visit
join
Home
Connect
about us
blog
calendar
contact us
havurah initiative
lay leadership
meet the team
learn
gan keshet preschool
alma: Youth & Family Education
ALMA Prospective Families
Enrolled Families
adult ed
b'nei mitzvah
teen life
act
tikkun olam
pray
high holy days
Minyanim
Outdoor Services during COVID-19
Service Schedule and Links
shabbat
farm
about abundance farm
pick your own
bakery
shared abundance gardens
Shabbat Shabloom
farm news and media
join
Give
donate
ways to give
Congregation B'nai Israel
Calendar
events
visit
join
Home
COVID-19 Symptom Questionnaire
COVID-19 Symptom Questionnaire
Please complete this form prior to participating in any on-campus programming.
*
First Name
*
Last Name
*
Email
*
Best Phone Number to Contact You
*
Have you had a fever over 100 degrees in the past 24 hours?
Please Select One
Yes
No
*
Are you having difficulty breathing or shortness of breath?
Please Select One
Yes
No
*
Have you recently lost your sense of taste or smell?
Please Select One
Yes
No
*
Do you or anyone in your household have a positive COVID-19 test result, or positive clinical diagnosis of COVID-19?
Please Select One
Yes
No
*
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 One
Yes
No
*
Do you or anyone in your household have a pending COVID-19 test due to illness or exposure?
Please Select One
Yes
No
*
Do you have nausea, vomiting, or diarrhea?
Please Select One
Yes
No
*
Do you have a sore throat?
Please Select One
Yes
No
*
Do you have any unexplained muscle or body aches?
Please Select One
Yes
No
*
Do you have a new or unexplained headache?
Please Select One
Yes
No
*
Do you have a new or unexplained cough?
Please Select One
Yes
No
*
Do you have nasal congestion or a runny nose, not due to other known causes such as allergies?
Please Select One
Yes
No
*
Before coming to our campus, please ensure that you are in compliance with the COVID-19 Travel Order which can be found here: https://www.mass.gov/info-details/covid-19-travel-order If you are out of compliance, please stay home.
Please Select One
I am in compliance
I will stay home
Would you like to make a donation to our COVID-19 Recovery Fund? ($0-$180)
Mon, October 26 2020 8 Cheshvan 5781
