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 to New York by air or from a foreign country within the last 10 days? *

Yes No
Have you quarantined for at least 10 days or received a negative COVID-19 PCR test after quarantining for at least 72 hours?* This requirement applies to all international or air travelers whether they were tested before boarding, are recovered from a previous COVID-19 infection, or are fully vaccinated. *

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
Should be Empty: