CBS Health Form

Congregation Bonai Shalom COVID-19 Health Screening and Attestation

We are guided by the Jewish value pikuach nefesh (saving a life), along with state and local guidelines to protect the health of our staff, students, teachers, families, and community.

In addition to agreeing to have your family members wear a mask (over nose and mouth) and maintain physical distancing while at CBS, we ask you to complete the following for each event/incident of entering the building you and or your family will attend. (Children under the age of 2 do not need to wear a mask. Children between 2 and 5 should wear a mask if they are able.)

Please answer the following questions and submit this form prior to your family's arrival at Congregation Bonai Shalom

Your Name

Child/ Children's Name (s)

* Email Address

Does you, your child or anyone in your household have a pending COVID-19 test or is scheduled to receive one prompted by the presence of symptoms (this does not apply to those tested only for travel purposes)?

YesNo

Have you, your child or anyone in your household had a positive COVID-19 test?

YesNo

In the past 14 days, have you or your child had close contact with a person known to be infected with the novel coronavirus (COVID-19)?

YesNo

If you answered YES to any of the above questions, you/your family cannot enter/attend without being cleared with a note from a healthcare provider.

If you answered Yes to any of the symptoms above, please do not plan to attend until cleared either by testing, your health care provider, or the symptoms abate. If the symptoms include a fever of 100^○F or above, your family cannot attend unless no one has had at least three days of no fever without taking medication to reduce fever during that time. If the symptoms include any respiratory symptoms (cough and shortness of breath), your family cannot attend unless the symptoms have resolved for at least 24 hours

Attestation

I agree that the above is true to the best of my knowledge

During the past 24 hours, has your child or any household members had any of the following symptoms: