COVID-19 Weekly Check-In - Chabad Jewish Center at Basking Ridge

Child's Name

First NameLast Name

Has your child taken fever reducing medicine today?

YesNo

Has your child or anyone in the household been in contact with anyone diagnosed with COVID-19 in the past 14 days?

YesNo

Does your child or anyone in the household have a cough, shortness of breath, or difficulty breathing?

YesNo

Does your child or anyone in the household have any 2 of the following symptoms? Headache, muscle pain, aches, fever, chills with physical shaking, loss of taste, or loss of smell

YesNo

Any other comments or concerns you would like to let us know?

Signed: Parent's Name

First NameLast Name

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