Holy Blossom Temple: Self-Assessment

To prevent the spread of COVID-19, to reduce the potential risk of exposure to our workforce and visitors, and to assist in any future contact-tracing, we thank you in advance for taking the time to fill out this brief self-assessment each day you visit HBT.

For details on COVID protocols in place at Holy Blossom Temple at this time, please visit: https://holyblossom.org/covid-update-reopening/.

Congregant/Visitor Name:

Here for work

I am here for work

For tradespeople, what company?

I will be at Temple:

Phone number

I do not have an email address

Additional members of my household are joining me

How many additional household members are with you today?

Name

Not yet 12 years old

Not yet 5 years old

Name

Not yet 12 years old

Not yet 5 years old

Name

Not yet 12 years old

Not yet 5 years old

Name

Not yet 12 years old

Not yet 5 years old

Name

Not yet 12 years old

Not yet 5 years old

1. Today, or in the last 5* days, have you experienced any of these symptoms? Fever or chills, new or worsening cough, new or worsening shortness of breath, runny nose or nasal congestion, sore throat, decrease or loss of sense of taste or smell, new or unexplained nausea, vomiting, diarrhea. abdominal pain, known or diagnosed pneumonia??

2. In the last 5* days, has any member of your household tested positive for COVID-19 or been told to stay home and self-isolate?

3. In the last 5* days, has any member of your household developed or experienced 1 or more new or worsening symptoms as outlined in #1 above?

4. In the last 14 days, have you or anyone in your household traveled outside of Canada in the last 14 days AND been advised to quarantine per the federal quarantine requirements?

*10 days for any household member who is immunocompromised or unvaccinated

By checking this box I confirm that I have read, understood, and answered NO to all of the questions above for myself and members of my household joining me

By checking this box, I confirm that if I have had previous Covid symptoms (symptoms that have been improving for 24 hours - 48 hours for nausea, vomiting and/or diarrhea), a positive test result, or a household member requiring isolation, that I have completed the required isolation period. (If you have had none of the above, please check the box.)

By checking this box I confirm that I and all members of my household joining me who are 5 years old or more have received two approved doses of the COVID-19 vaccine (and it has been at least two weeks since the date of the second dose).

By checking this box I confirm that it is my/our responsibility to wear a mask properly, and maintain physical distance as well as respect the wishes of others who choose to maintain distance.

Date

Initials

Purpose of Visit

Please Specify

Time of entry

Time of day

AMPM

child under 12 in group

Child under 12 in household

PASS

Yes

Holy Blossom Temple: Self-Assessment - One per Household