Covid Health Screening - Riverdale Temple

Your Name*
First Last
ARE YOU EXPERIENCING A FEVER OF 100 DEGREES F OR GREATER, A NEW COUGH, SHORTNESS OF BREATH, ABDOMINAL PAIN, FATIGUE, BODY ACHES, MILD RUNNY NOSE, CHILLS, LOSS OF TASTE, SORE THROAT?*
- No
- Yes
IN THE PAST 10 DAYS, HAS ANYONE IN YOUR HOUSEHOLD TESTED POSITIVE FOR COVID-19 OR IS ANYONE IN YOUR HOUSEHOLD CURRENTLY WAITING FOR RESULTS OF A COVID-19 TEST?*
- No
- Yes
IN THE PAST 10 DAYS, HAVE YOU GOTTEN A POSITIVE RESULT FROM A COVID-19 TEST THAT TESTED SALIVA OR USED A NOSE OR THROAT SWAB? (NOT A BLOOD TEST)*
- No
- Yes
TO THE BEST OF YOUR KNOWLEDGE, IN THE PAST 14 DAYS, HAVE YOU BEEN IN CLOSE CONTACT (WITHIN 6 FEET FOR AT LEAST 10 MINUTES) WITH ANYONE WHILE THEY HAD COVID-19?
- No
- Yes
WITHIN THE PAST 7 DAYS, HAVE YOU ATTENDED A LARGE GATHERING, OR HAVE YOU TRAVELED OUT OF STATE?*
- No
- Yes
PLEASE DO NOT GO TO SCHOOL TODAY.
Note: If you have traveled to one of the states that is on the red zone list you must quarantine for 14 days.

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	administrator@riverdaletemple.org
	P: (718) 548-3800 F: (718) 543-1492
	4545 Independence Avenue Bronx, New York 10471

24/7 Life Cycle Emergency:
(718) 548-3800 X 7 (congregants only)