COVID SCREENING - Form - Temple Sinai Summit

The good health and safety of the Temple Sinai Community is of prime concern.

Please complete this brief questionnaire to help assess whether or not you should come to the Temple. This screening tool is based on recommendations from the Centers for Disease Control and Prevention. It should not be a substitute for professional medical advice, diagnosis, or treatment. It is only for screening related to COVID-19.

It is mandatory that this form be completed before you come to the Temple.

If you are experiencing any of the symptoms listed in the survey, please do not come to the Temple and consult a medical professional.

Thank you!

First Name

* Last Name

* Have you or anyone in your household had any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 F?

Please Select OneYesNo

* To the best of your knowledge have you been near any individual who tested positive for COVID-19?

Please Select OneYesNo

Travel guidelines for unvaccinated Individuals: In order to attend services or programs at the temple, anyone who is traveling to NJ from states outside the immediate region (NY, DE, CT, PA), should have a COVID test 1-3 days before traveling, and receive a negative result. Any NJ resident who is traveling to a state outside the immediate region (NY, DE, CT, PA), should get tested with a viral test 3-5 days after returning home AND stay home and self-quarantine for a full 7 days after travel. Even if you test negative, stay home and self-quarantine for a full 7 days before attending service or programs at the temple.

YesNoRegarding the Travel Guidelines, please check YES to confirm that you have met the above requirements for service attendance.

* Remaining socially distanced and wearing a face mask are required while inside the Temple.

I agree to wear a face mask at all times.I agree to maintain a social distance of 3-6 feet from individuals outside of my family unit.