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COVID-19 Self Screening

Visitors and Employees

Everyone Entering Temple Israel Must Complete This Self-Screening

The safety of our employees and visitors remains a priority for Temple Israel. As the coronavirus (COVID-19) outbreak continues to evolve and spread globally, Temple Israel is monitoring the situation closely and will periodically update the guidance based on current recommendations from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).

To help prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone onsite.  While your safety is a priority for Temple Israel, by signing this form, you understand and voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Temple Israel and any of its employees or affiliates liable for illness or injury.

Contact Information
About Your Visit
Family Check-In

You may check in other family members and people who reside with you. Your answers in the Health Information section will apply to everyone you name here as well.

Health Information

Your answers in this section apply to everyone named on this form.

Are you showing any signs of one or more of the following symptoms?

Temperature of 100.4°F (38°C) or higher, cough, shortness of breath, difficulty breathing, tiredness, lack of taste and smell, chills, repeated shaking with chills, muscle pain, headache, sore throat, runny nose or new sinus congestion, new GI symptoms

Have you traveled internationally in the past month?

Have you had close contact with a confirmed/probable COVID-19 case?

Is the information provided on this form true and correct to the best of your knowledge?

Signature & Acknowledgment

Checking the box below constitutes your signature that you have filled out this form for everyone named in it.

Directions for Employees & Hosting Visitors

Please adhere to Temple Israel’s pandemic preparedness and response guidelines with respect to being onsite. This means: 

  • The COVID-19 Employee & Visitor & Self Screening form is to be completed on a daily basis.
  • The COVID-19 Employee & Visitor & Self Screening form can be printed and completed prior to arrival. Please present the document during the screening process upon arrival.
  • Visitation or contractor work is forbidden if there has been any YES response to questions 1 or 2 on the Employee & Visitor Self Screening form. If YES is checked for questions 1 or 2, please advise the individual to leave the premises, notify appropriate site personnel to disinfect any common surfaces touched by the visitor and advise HR of the incident.
  • Visits that do occur should limit exposure to students and employees to the extent feasible, by:
    • Ensuring all individuals onsite wear cloth face masks to slow the spread of the virus as recommended by the CDC and WHO.
    • Ensuring visitors take a direct route to meeting or work areas and do not unnecessarily interact with employees.
    • Practicing Social Distancing at all times and instructing visitors regarding our expectations of social distancing (i.e. no handshakes or embraces, keeping 3-6 feet [1-2 meters] distance when interacting, etc.).
    • Practicing expected hygiene regarding washing hands and covering coughs/sneezes, pointing out or providing Temple Israel’s guidance on this topic.
    • For visitors, use designated meeting rooms where possible, which should have common surfaces disinfected between meetings.

Fri, April 19 2024 11 Nisan 5784