COVID-19 Health Screening Questionnaire
Everyone entering Stephen Wise Free Synagogue must complete and sign this health screening form. Screening should be done at the beginning of the work or school day or, for worshippers or visitors, at least two hours prior to entry. The information you provide will be stored in a HIPAA-compliant environment. Upon completion of this form, you will receive an email indicating whether or not you may enter the synagogue building. Please show that email to the security guard when you arrive at the synagogue. Our security guard will have access only to data that will enable them to ensure those eligible are granted access.
Please enter a valid phone number.
Have you had any of the following symptoms in the past 24 hours or close contact with a suspected COVID-19 patient within the past two weeks? Chills; a temperature of 100.4 degrees Fahrenheit or greater; cough (productive or dry); sore throat; shortness of breath or difficulty breathing; muscle pain or body aches; new loss of taste or smell; vomiting; or diarrhea.
Should be Empty: