(516) 767-8672

Health Assessment

Please complete this questionnaire each Sunday morning
before Hebrew School.

  • Date Format: MM slash DD slash YYYY
  • First, Last
  • In the past 14 days, have you experienced symptoms of COVID-19 ?
  • In the past 14 days, have you been in close contact (within 6 feet for more than 10 minutes) with anyone who has tested positive for, or who has symptoms of, COVID-19?
  • In the past 14 days, have you spent longer than a 24-hour period of time in a state that is, or was before you left the state, subject to quarantine restrictions on travelers arriving in New York State? (current list of travel restricted states)