Sign In Forgot Password

B'nai Mitzvah Health Assessment

This questionnaire should be filled out based on all those who will be attending the service in person. All must be listed.
Please report any symptoms, even subtle ones. Thank you.

 
Today, do you, or does anyone you plan to have in the Sanctuary for the service have:
(not related to chronic condition, e.g., asthma, allergies, smoker’s cough)
(not related to chronic condition, e.g., asthma, allergies, smoker’s cough)
Different than usual allergies
Different from usual allergies?
To help us ensure a safe environment, as you have answered 'yes' to one of the above questions, please contact Executive Director Steve Winer by phone at 617-794-3752 or email at executivedirector@cbnaishalom.org as soon as possible. Thank you for your understanding.
In the past 14 days have you, or anyone listed above planning to attend the Sanctuary service:
(If unsure whether that location is high prevalence, ask your doctor.)
To help us ensure a safe environment, as you have answered 'yes' to one of the above questions, please contact Executive Director Steve Winer by phone at 617-794-3752 or email at executivedirector@cbnaishalom.org as soon as possible. Thank you for your understanding.
Please ONLY answer yes if anyone has been in a state NOT identified as lower risk by the Commonwealth of Massachusetts. 
Please provide the following information:
  • Name
  • Date of most recent vaccination
  • Was this vaccination 1 or 2 of Pfizer or Moderna, or the Johnson & Johnson Janssen single dose vaccine?
     
To help us ensure a safe environment, as you have answered 'yes' to one of the above questions, please contact Executive Director Steve Winer by phone at 617-794-3752 or email at executivedirector@cbnaishalom.org as soon as possible. Thank you for your understanding.
Tue, April 13 2021 1 Iyar 5781