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.
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Name
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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?
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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.
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Yes
No
Within the past two weeks, have you had close contact with a suspected or known COVID-19 patient?
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Yes
No
Have you traveled to New York from any foreign country or any of the following U.S. states or territories in the last 14 days? Alaska, Alabama, Arkansas, Arizona, California, Colorado, Delaware, Florida, Georgia, Guam, Iowa, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Mississippi, Montana, North Carolina, North Dakota, Nebraska, New Mexico, Nevada, Ohio, Oklahoma, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, West Virginia, Wyoming.
*
Yes
No
Signature
*
Use your mouse or finger to draw your signature above.
Clear
Submit
Should be Empty: