COVID-19 Health Screening Checklist

Temple Shir Tikvah is deeply concerned for the welfare of our community, particularly in light of the risks posed by COVID-19, and are taking steps to help limit the spread of COVID-19 at events sponsored by the Temple. By participating in person, you agree to abide by the protocols and instructions established by the Temple's clergy, professional staff and lay leadership and is available on our website. Unfortunately, it is impossible to be sure that participating in an in-person event will not result in exposure to COVID-19 and so we ask that each community member make their own decision about what level of risk is appropriate for them.
ALL guests are required to answer the following questions.

* Name of event

Covid-19 Vaccination Requirements
Ages 5+: Full vaccination and booster shot (three doses of Pfizer or Moderna; or one dose of J&J plus a booster shot).

* Please check here: I attest that I have been vaccinated against Covid-19, according to the above requirements.

Please check here: I attest that I have been vaccinated against Covid-19, according to the above requirements.

* Please check here: If I test positive for Covid-19 in the next 10 days, I will contact the Temple office immediately: office@shir-tikvah.org or 781-729-1263

Please check here: If I test positive for Covid-19 in the next 10 days, I will contact the Temple office immediately: office@shir-tikvah.org or 781-729-1263

Please answer the following questions. If you answer "yes" to any question, we respectfully ask that you not attend.

Within the last 10 days, have you...

* tested positive for Covid-19?

Please Select OneYesNo

* had contact with anyone that you know had Covid-19?

Please Select OneYesNo

* developed new fever?

Please Select OneYesNo

* developed new or worsened cough or shortness of breath?

Please Select OneYesNo

* Please sign by typing your name below. If you answered "Yes" to any question above, we respectfully ask that you do not attend the event.

* Email:

* Date

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