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.

* Name of 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 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

Do you have any of the following symptoms? Please answer "Yes" or "No" to the following questions:

* New fever or chills?

YesNo

* New or worsened cough?

YesNo

* New or worsened shortness of breath?

YesNo

* New sore throat?

YesNo

* New or worsened muscle aches?

YesNo

* New or worsened headaches?

YesNo

* New loss of smell or taste?

YesNo

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

YesNo

* Please sign by typing your name below:

* Email:

* Date

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