Health Screening Questionnaire

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

Yes

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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?

Yes

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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

Yes