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.
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Have you had any signs or symptoms of a fever in the past 24 hours — such as chills, sweating, or a temperature of 100.4 degrees Fahrenheit or greater?
*
Yes
No
Do you have any of the following respiratory symptoms? 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.
*
Yes
No
Within the past two weeks, have you had close contact with a suspected or known COVID-19 patient?
*
Yes
No
Have you traveled to New York from any foreign country or any U.S. state or territory that is not contiguous with New York state in the last 14 days?
*
Yes
No
I certify that I have followed the latest New York state travel guidelines: Anyone traveling to New York from a non-contiguous state and who was outside of New York for more than 24 hours must quarantine for 14 days OR: (1) must obtain a negative COVID test within three days of departure from that state; (2) upon arrival in New York, quarantine for three days; and (3) obtain another negative COVID test on the fourth day of quarantine. If both tests come back negative, the traveler may exit quarantine early upon receipt of the second negative diagnostic test. Travelers who were in another state for less than 24 hours do not need a test prior to their departure from the other state, and do not need to quarantine upon arrival in New York State; however, those travelers must fill out New York state's traveler health form upon entry into New York and take a COVID diagnostic test four days after their arrival in New York — OR they may choose to quarantine for 14 days. Travelers from states that are contiguous with New York will continue to be exempt from the travel advisory as will essential workers.
*
Yes
No
Signature
*
Use your mouse or finger to draw your signature above.
Clear
Submit
Should be Empty: