(UPDATED 1.25.21) B'nai Shalom Daily Health Screening
Anyone who enters the building must first submit this form. If you do not pass the screening, an alert will be sent to the email address you enter below and someone from the B'nai Health Team will be in touch ASAP.
Please read the questions carefully, as the form has recently been updated.
* Required
Email address
*
Your email
Parents must submit this form on behalf of their children before drop-off. Staff and other adults who enter the building must fill this out each day prior to arrival.
FIRST NAME of individual(s) entering the building today:
Your answer
LAST NAME of individual(s) entering the building today:
*
Your answer
Have you, your student, or anyone your household(s) been diagnosed with COVID-19 in the past 14 days?
*
Yes
No
If you have ANY of the primary symptoms below, STAY HOME and contact the school for next steps.
Have you, your student, or anyone in your household(s), had any of the following primary symptoms since they were last at school?
*
Fever/Chills
Shortness of Breath or Difficulty Breathing
New or Worsening Cough
New Loss of Taste or Smell
None of the above
Required
If you have 2 OR MORE of the secondary symptoms below, STAY HOME and contact the school for next steps.
Have you, your student, or anyone in your household(s), had any of the following secondary symptoms since they were last at school?
*
Sore Throat
Nausea/Vomiting/Diarrhea
Muscle Aches
Headache
Fatigue
Rash
New or Worsening Nasal Congestion/Drainage
None of the above
Required
Have you, your student, or anyone in your household(s), had close contact with someone diagnosed with COVID-19 in the last 14 days? (close contact = within 6 feet for a cumulative total of 15 minutes over a 24 hour period)
*
Yes
No
Has any health department staff or healthcare provider advised you, your student, or anyone in your household(s) to quarantine?
*
Yes
No
Do you, your student, or anyone in your household(s) have a pending covid test?
*
Yes
No
The next two questions ONLY refer to the person entering the building
Has your student (for staff - have you) gathered with 10 or more people indoors or 25 or more people outdoors since they were last at school?
*
Yes
No
Has your student (for staff - have you) traveled by air, bus, train or any other mode of transportation that required close contact (within 6 ft.) with people outside your household for more than 15 minutes since they were last at school?
*
Yes
No
Based on the answers to the questions above, WHO FAILED THE SCREENING? (write "n/a" if not applicable).
*
Your answer
By typing my name below, I affirm that all of the above information is true and accurate, and understand that our public health at the school relies on my honesty.
*
Your answer
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