Health Survey

First name

Last name

Mobil Phone

* Have you completed COVID-19 vaccination (2 weeks after J&J, 1 week after second shot of Pfizer or Moderna)

Please select oneYesNo

* In the last 14 days, have you or any member of your household experienced any of the following:

Fever (over 100.4 degrees F)Coughing, sore throat or congestionHeadaches or bodyachesVomiting or diarrheaShortness of breath or difficulty breathingPersistent pain, pressure or tightness in chestLoss of sense of smellTravel to areas with high community spread of COVID-19None of the above

* Close contact

Please select oneYesNoHave you or anyone living at home come into close contact with COVID-19 positive patients in the work place?

* Diagnosis of COVID-19 infection?

Please select oneYesNoHave you or a household member, or any known close contact had a diagnosis of COVID-19 infection?

* Electronic signature

Please select oneYesNoI agree that this acts as an electronic signature agreeing to the veracity of the information above and if the answer to any of these questions changes before the event, I will notify Temple Beth Shalom as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I will not be entering the building.

* Assumption of possible exposure

Assumption of possible exposureBy entering the property I acknowledge that there is an assumption of exposure to the Coronavirus (COVID-19) and any and all consequences that may result from such exposure, including but not limited to, physical injury, psychological injury, pain, suffering, illness, temporary or permanent disability, death or economic loss. This form is intended to notify the parties of the risks associated with visiting Temple Beth Shalom. By checking this box and submitting this form, I hereby acknowledge and assume such risks and/or potential consequences. I acknowledge receipt of this Coronavirus (COVID-19) Limitation of Liability Form and understand that the refusal to sign this form may result in the refusal to allow me to enter the premises.

Upload either a copy of Covid-19 Vaccination Record Card or a copy of a Negative Covid-19 test.

Note:
If you are vaccinated, you don't need to do this again.
If uploading a test result, it must be within 72 hours of visiting Temple Beth Shalom.

If you are unable to upload the form, you can mail a copy of the form to
Temple Beth Shalom
760 Route 6, Mahopac, NY 10541

or make an appointment with the office by calling (845) 628-6133

Temple Beth Shalom Health Screening Form