LT COVID-19 VISITOR SCREENING FORM
*** KESHER STUDENTS: If you are submitting this form for student attending KESHER, please go to the correct form at this link:   https://formfaca.de/sm/JQWGS8fF0 ***

This questionnaire must be submitted by all visitors to Larchmont Temple's building or attendees of a physical Larchmont Temple event ON THE SAME DAY they seek to enter/attend (not the day prior; note a new questionnaire must be completed EACH DAY you come).

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location or attend the event. If you answer “YES” to any of the questions, or after you complete this questionnaire but at the time you plan to enter/attend your answer would be "YES" , please DO NOT enter Larchmont Temple's building or attend the event.

If you are answering this questionnaire for multiple people IN YOUR HOUSEHOLD who are accompanying you, you must answer "YES" to a question if any of these people's answers would be "YES".
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First name: *
Last name: *
Number of other members OF YOUR HOUSEHOLD accompanying you. *
Email or phone number where you can be reached *
SYMPTOMS.  Are you experiencing or in the past 14 days have you experienced any of the known COVID-19 symptoms (fever of 100 degrees or higher, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea)?  (If yes but since cleared by a doctor, answer "No") *
COVID TESTING.  Have you tested positive for COVID-19 in the past 14 days)?   (If yes but since cleared by a doctor, answer "No") *
CONTACT.  To your knowledge have you had "close contact", which can include multiple brief contacts over a 24-hour period, with one or more people who experienced symptoms of or tested positive for COVID-19 within the last 10 days?  (If yes but since cleared by a doctor, answer "No") *
US TRAVEL.  New York no longer requires quarantine after domestic (US) travel, although quarantine and testing within 3-5 days of return is still recommended for domestic travelers who are not fully vaccinated or have not recovered from laboratory confirmed COVID-19 during the previous 3 months.  Please answer "No" to this question. *
INTERNATIONAL TRAVEL.  New York no longer requires quarantine after international travel, although quarantine and testing within 3-5 days of return is still recommended for travelers who are not fully vaccinated or have not recovered from laboratory confirmed COVID-19 during the previous 3 months.  Please answer "No" to this question. *
QUARANTINE.  Have you been advised by a doctor or any local, state or federal authority to be in quarantine at this time? *
By submitting this questionnaire, you certify that all of the answers are accurate to the best of your knowledge, and you will comply with LT's guidelines and policies relating to COVID-19.  
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