Adult Health Survey Thank you for your interest in attending TNT Service or other programs. Please fill out this survey 2-3 hours before you plan to attend a program or service at TNT to confirm your health and attendance. TNT Service signupTemple Ner Tamid Friday, (Date) 8:00 PM Question Title * 1. Your contact info: First Name * Last Name Home * City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Phone Number * Question Title * 2. Do you now have or in the past 48 hours have had a temperature of 100.4F or greater? Yes No Question Title * 3. Do you have a cough? (new onset, or worsening in the past 48 hours?) Yes No Question Title * 4. Are you short of breath? (New onset, or worsening in the past 48 hours.) Yes No Question Title * 5. Have you been in direct contact with anyone who has the above symptoms or has been diagnosed with COVID - 19 within the past 14 days? Yes No Question Title * 6. Have you lost your sense of smell? Yes No Question Title * 7. Have you recently developed any abdominal pain &/or diarrhea not consistent with a pre existing condition. Yes No Question Title * 8. My answers are truthful and answered to the best of my ability. Yes No Question Title * 9. I understand that If I answered yes to any of questions 4-9, that I need to call my healthcare provider for medical advice and to provide medical authorization in the form of written communication for me to attend future services or programs at TNT. Alternatively, I will provide proof of a negative Covid-19 test. Until that time, I will not attend Services, programs or enter the TNT building. Approve Disapprove Question Title * 10. I understand that I am expected to wear a mask when I am in the Synagogue Building - I will not bring any food or drink - I understand that I am not permitted to sing while in the Synagogue. I agree to abide by all Policies and Procedures set forth by TNT Agree Disagree Question Title * 11. I understand that there will be a limited number of attendees allowed to attend the services or programs and that I will not attend or show up at the Temple if my attendance has not been confirmed by TNT in advance. Agree Disagree Question Title * 12. This form must be filled out 2 to 3 hours before the Service or program. Date / Time Date Time AM/PM - AM PM Page1 / 1 100% of survey complete. Done
