Island Synagogue Vaccination Survey Question Title * 1. What is your name? Please fill out this survey once for each member of your family who attends services in person. Question Title * 2. Are you fully vaccinated at this time (14 days since final dose) Fully vaccinated Not fully vaccinated Question Title * 3. If not, when did you have your second/final shot, or when are you scheduled to have it? Date / Time Date Question Title * 4. Please confirm that you will honor the Healthy Community Guidelines consistent with your vaccination status: Yes HEALTHY COMMUNITY CAMPAIGN GUIDELINES 2021.05.20 TAKE THE COVID-19 VACCINE (UNLESS YOUR PHYSICIAN ADVISES OTHERWISE) PLEASE STAY HOME IF YOU HAVE COLD, FLU, FEVER, OR COUGH SYMPTOMS PLEASE STAY HOME IF YOU HAVE TESTED POSITIVE FOR COVID-19 IN THE PAST 14 DAYS IF YOU HAVE NOT BEEN FULLY VACCINATED (14 days since final dose), PLEASE HELP PROTECT YOURSELF AND OTHERS: WEAR A MASK WHILE YOU ARE ON THE PREMISES OR IN PUBLIC AREAS PRACTICE SOCIAL DISTANCING BY MAINTAINING A MINIMUM OF 6 FEET SEPARATION FROM EVERYONE ELSE (except members of the same household) USE HAND SANITIZER OR WASH HANDS FREQUENTLY PLEASE STAY HOME (EVEN IF YOU HAVE NO SYMPTOMS) IF YOU HAVE NOT BEEN FULLY VACCINATED AND: YOU HAVE A HOUSEHOLD MEMBER WITH COVID-19 SYMPTOMS OR YOU HAVE HAD EXPOSURE TO SOMEONE WITH COVID-19 SYMPTOMS IN THE PAST 14 DAYS, or YOU HAVE TRAVELED OUT-OF-STATE IN THE PAST 10 DAYS, or YOU HAVE SOCIALIZED INDOORS WITH NOT FULLY VACCINATED PEOPLE OUTSIDE OF YOUR IMMEDIATE FAMILY IN THE PAST 10 DAYS VACCINES, MASKS, SOCIAL DISTANCING, & CLEAN HANDS SAVE LIVES.THANK YOU FOR YOUR COOPERATION. Done