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 patrons are required to answer the following questions.
Information provided will determine whether access is permitted.

* Event Attending

* Within the last 14 days, have you had contact with anyone that you know had COVID-19 or COVID-19 like symptoms?

Please Select OneYesNo

* Please check here: If I become sick with COVID-19-like symptoms 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 become sick with COVID-19-like symptoms in the next 10 days, I will contact the Temple office immediately: office@shir-tikvah.org or 781-729-1263

Please check here: I attest that I have been fully vaccinated against Covid-19. (Required for any indoor event, for ages 12 and up)

Please check here: I attest that I have been fully vaccinated against Covid-19. (Required for any indoor event, for ages 12 and up)Note: This is not required for b'nei mitzvah ceremony guests until November 1.

Do you have any of the following symptoms? Please answer "Yes" or "No" to the following questions. If you answer "Yes" to any question, we respectfully ask that you do not attend the event.

* New fever or chills?

Please Select OneYesNo

* New or worsened cough?

Please Select OneYesNo

* New or worsened shortness of breath?

Please Select OneYesNo

* New sore throat?

Please Select OneYesNo

* New or worsened muscle aches?

Please Select OneYesNo

* New or worsened headaches?

Please Select OneYesNo

* New loss of smell or taste?

Please Select OneYesNo

* Have you traveled outside the United States in the last 14 days?

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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