Weekly Health Screening Questionnaire
Chabad of Potomac Hebrew School
Email address *
Name of Student *
Date *
Has anyone in your family been exposed to anyone suspected or confirmed to have COVID-19 in the past 14 days? *
Has anyone within the family or household traveled out of state in the past 10 days? If yes please write where in the "other" option *
Has the student or any members of the household developed ANY of the following symptoms of COVID-19 infection in the last 10 days?
Thank you for filling out the Health Questionnaire and ensuring the safety of the staff and students @ Chabad Hebrew School!
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Chabad Shul of Potomac. Report Abuse