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2021 Chanukah 5782
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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
What program do you plan on attending?
*
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
Would you like to make a donation to our COVID-19 Recovery Fund? ($0-$180)
Mon, December 6 2021 2 Tevet 5782
