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Health Assessment Form

This questionnaire should be filled out based on all those who will be entering the building. All must be listed.
 
Today, do you, or does anyone listed above 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:
(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.
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