NCSY Daily Screening Questionnaire Name* First Last Email* Phone*I am attending an in person program with this person:*Make a SelectionRabbi Shmuel BarakAvi WarmanJennifer RomanoffRabbi Aryeh BerzonAriel BugayDavid CohenRachel BrecherRabbi Moshe FreilichRabbi Eli LobRabbi Joey HamaouiDaniel NabatianI don't know1) In the last 14 days, have you been diagnosed with Coronavirus/COVID 19?* Yes No 2) In the last 14 days, have you been tested for Coronavirus/COVID 19?* Yes No 3) If YES, what type of test did you take?* N/A Rapid PCR 4) If YES, what was the result of this test* N/A Negative Positive Not Back Yet 5) In the last 14 days, has anyone in your immediate household (relative, roommate) been tested for or diagnosed with coronavirus/COVID 19?* Yes No 6) In the last 14 days, have you been in close contact (within 6 feet for longer than 10 minutes) with someone who tested positive or was diagnosed with Coronavirus, or is awaiting test results?* Yes No 7) In the last 14 days, have you been in close contact with anyone experiencing fever, cough or who appeared ill?* Yes No 8) In the last 14 days, have you developed any of these symptoms* Yes No a. Fever or chills b. Cough, shortness of breath or difficulty breathing c. Fatigue, muscle or body aches d. Headache e. New loss of taste or smell f. Sore throat, congestion or runny nose g. Nausea, vomiting or diarrhea
Southern NCSY