Coronavirus Reporting Form

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Thank you for taking the time to notify us of your Coronavirus Diagnosis.
It is our priority to ensure the health and safety of our members and guests.
The purpose of this form is for us to be informed of your situation so that we can be of service to you and your family as best we can, and to check our records should contact tracing be necessary.

This form is NOT intended to provide any medical assistance or advice.
Please contact your health care provider with any medical questions.

* First Name

* Last Name

Last Date Visited Beth Jacob Irvine

* Date of Positive Test / Exposure / Symptom Onset

Please select all that apply:

Add My Name to Refuah ShleimaI Need Help with Grocery ShoppingI Need Help with MealsI am currently in the HospitalI am concerned I may have exposed others in the communityPlease do NOT share my diagnosis with anyone outside of Beth Jacob Staff

We will do our best to assist you in any way we can with shopping, meals, etc. As a community, we want to do as much as we can to come together during this difficult time as cases are rising and members of our community are in need of assistance.

If you have any other information, questions, thoughts, concerns, or comments, please fill out the section below:

Sat, April 20 2024 12 Nisan 5784