Weekly Health Screening Questionnaire
Chabad of Potomac Hebrew School
Name of Student
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?
Fever (100.4°F or higher)
Shortness of Breath
Chills or Shaking
Congestion or Runny Nose
Loss of Taste or Smell (adults only)
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.
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This form was created inside of Chabad Shul of Potomac.