COVID-19 Health Screening Questionnaire

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 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 domestically by air or internationally within the last 10 days?* *

Yes No
Are you fully vaccinated against COVID-19 and able to produce proof of your last vaccination? (i.e., you are beyond two weeks after a two-dose series or four weeks after a single-dose vaccine.) Please show proof of vaccination by (in the form of your CDC vaccination card or your digital New York State Excelsior Pass). *

Yes No
Did you receive a negative COVID-19 PCR test 1–3 days before your trip and have you quarantined for at least 10 days following the conclusion of your trip? *

Yes No
Did you (1) receive a negative COVID-19 PCR test 1–3 days before your trip AND (2) following travel, did you receive a negative COVID-19 PCR test after 3–5 days and self-quarantine for 7 days? *

Yes No
*Stephen Wise Free Synagogue, in consultation with its team of advisors, is maintaining a COVID safety policy that may be more strict than official New York state guidelines.
Signature *

Use your mouse or finger to draw your signature above. Clear
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