All participants are required to complete this questionnaire before entering the building.

The JCCSF cares about the health and well-being of our community. Due to the COVID-19 outbreak, we are taking precautionary measures to keep the building safe for everyone.

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* 1. Full Name

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* 2. In the last 24 hours, including today, have you had ANY of the symptoms below, that is new or not explained by another condition?
  • Fever (100.4 F/38 C or greater), chills, shivering
  • Cough
  • Sore throat
  • Shortness of breath, difficulty breathing
  • Feeling unusually weak or fatigued*
  • Loss of taste or smell
  • Muscle or body aches*
  • Headache
  • Diarrhea
  • Runny or congested nose*
  • Nausea or vomiting
*Children and youth under 18 years old do not need to be screened for these symptoms

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* 3. Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus?

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* 4. In the past 10-14 days, have you had “close contact” with anyone who has COVID-19, during their contagious period?

“Close contact” means having any of the following interactions with someone with COVID-19 while they were contagious (they are contagious 48 hours before their symptoms began until at least 10 days after the start of symptoms). If the person with COVID-19 never had symptoms, they are contagious 48 hours before their COVID-19 test was collected until 10 days after they were tested.
  • Within 6 feet of them for a total of 15 minutes or more in a 24-hour period
  • Having direct contact with their bodily fluids (coughed or sneezed on you or shared food utensils)
  • Living or staying overnight with them
  • Having physical or intimate contact including hugging and kissing
  • Taking care of them, or having them take care of you

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