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Hatzalah/TGS COVID Survey
ONE FORM FOR EACH MEMBER OF THE FAMILY. AFTER SUBMITTING, YOU CAN CLICK "SUBMIT ANOTHER RESPONSE".
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* Indicates required question
Are you a member of the Crown Heights community? (Including past Eastern Parkway, East Flatbush, Midwood area, etc)
*
Yes
No
What is your gender?
*
Male
Female
What is your current age?
*
Your answer
What is your email address? This is voluntary, but would be helpful if possible.
Your answer
Please check if you have any of the following:
Diabetes
High Blood Pressure
Asthma
COPD
Please check if you've had any of the following new symptoms since Purim, please check as appropriate:
*
No symptoms
Fever
Cough
Shortness of breath
Sore throat
Muscle aches
Unusually low energy
Nausea
Diarrhea
Loss of smell/taste
"Burning" chest
Headache
Had other symptoms
Required
If possible, around what date do you think the symptoms began?
MM
/
DD
/
YYYY
How bad were your symptoms, on a scale from 1 (very mild) to 5 (quite severe)?
1
2
3
4
5
Clear selection
During the course of your symptoms, did you feel as though you began to get better, and then got worse again?
Yes
No
Unsure
Clear selection
For the above symptoms, how many days did symptoms last total? (If you still have symptoms, indicate how many days thusfar)
Choose
1
2
3
4
5
6
7
8
9
More than 9
Have all your symptoms resolved?
Yes
No
Yes except for sense of smell/taste
Clear selection
If you no longer have symptoms, how many days has it been since you've NO LONGER had symptoms? (Not counting smell/taste)
Choose
Still have symptoms
1
2
3
4
5
6
7
More than 7
Have you been tested for COVID?
*
No
Yes, waiting for results
Yes, results positive
Yes, results negative
Did you fill out the first Hatzalah survey that went around a little while ago (with somewhat similar questions)?
*
Yes
No
Don't remember
How many family members live in this household?
*
Your answer
How many family members got sick (including yourself)? (And PLEASE fill out a separate form for each one of them)
*
Your answer
What are the last 4 digits of the phone number of the primary family member filling out this form? (This helps us understand which forms belong to the same family, without identifying the family)
Your answer
What is the first letter of your last name?
Your answer
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