Health Screening Questionnaire

DONATE

DONATE

Your safety is our biggest priority. Before entering the building, please fill out the following questionnaire. If you answer yes to any of the questions, please do not enter the building without first checking with Rachel, Sheila or Paulette, (212) 838-2122.

Thank you.

* Which service(s) on what day(s) do you plan to attend?

* First Name

* Last Name

* Email

* Phone Number

* Have you had a diagnosis of or suspected diagnosis of COVID-19 in the past 14 days?

* Have you been exposed to confirmed or suspected COVID-19 in the past 14 days?

Have you had any of the following new symptoms in the past 14 days (not due to a chronic preexisting condition)?

* fever(100.4 F or higher), chills or shaking

* cough, shortness of breath or difficulty breathing

* headache

* sore throat

* muscle aches

* diarrhea, nausea, vomiting or abdominal pain

* runny nose

* new loss of sense of taste or smell (for adults)

* In the past 14 days, have you traveled internationally or returned from a state identified by New York State as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)? Visit https://coronavirus.health.ny.gov/covid-19-travel-advisory for more information.

Mon, April 12 2021 30 Nisan 5781