Building Entry Wellness Questionnaire (Visitor)
Please complete the below questionnaire up to
before entering a PAS building.
Building to Enter
50 E. 87th Street (PAS@87th)
11 E. 89th Street (PAS@89th)
In the past 14 days have you tested positive for COVID-19?
Have you been vaccinated against COVID-19 (two weeks post your final vaccine dose)?
In the past 72 hours, have you had any of the following symptoms: 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 degrees Fahrenheit?
In the past 72 hours, have you or anyone in your household had any of the following symptoms: 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 degrees Fahrenheit?
To your knowledge, within the past 10 days, have you or anyone in your household been exposed to, or cared for, someone diagnosed with, exhibiting symptoms of, or reasonably suspected to have COVID-19? Exposure means a household member, intimate partner, or other individuals in prolonged close contact (within 6 feet for 10 minutes or more).
I understand that the synagogue may provide my contact information to state or local health authorities for contract tracing purposes in the event of a positive case of COVID-19. I acknowledge and agree that the foregoing is reasonable and necessary to protect my safety and health as well as the safety and health of others (including synagogue employees, students, and visitors).
COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the CDC, senior citizens and people with underlying medical conditions are especially vulnerable.
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.