ECC & RS Health Screening Questionaire - Form - Greenburgh Hebrew Center

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ECC & RS Health Screening Questionaire

GHC ECC and RS Health Screening Questionaire

Does your child have or have had in the past 14 days:

FeverChillsSweatsMeasured temperature of 100.4F or greaterMaiaise/FatigueLoss of sense of smellLoss of sense of tasteCoughChest PainShortness of BreathSore ThroatNauseaVomittingDiarrheaHave you or your child been in direct contact with someone that tested positive for Covid-19 in the past 14 days?Have you or your child been diagnosed with Covid-19 within the past 14 daysHas your child traveled internationally in the past 14-daysHas your child traveled by air, car or train, out of the tristate area in the past 14 days?

* Printed Child's Name

* Parent/Legal Guardian who completed this form

* Email address

* Date

Thu, January 27 2022 25 Shevat 5782

Greenburgh Hebrew Center
515 Broadway
Dobbs Ferry, NY 10522
(914) 693-4260

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