LT COVID-19 VISITOR SCREENING
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 your 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".
First name: *
Last name: *
Number of other members OF YOUR HOUSEHOLD accompanying you. *
Email or phone number where you can be reached *
Are you experiencing or in the past week have you experienced any of the following symptoms? Check any that apply (each is considered a "YES" answer), or NONE OF THE ABOVE otherwise. *
Required
Have you tested positive for COVID-19 and not subsequently tested negative? *
To your knowledge have you had contact with someone who has experienced symptoms of or tested positive for COVID-19 within the last 14 days? *
In the last 14 days (but only since or until the relevant date(s) specified below, if any), have you been in any of the following US states or territories (excluding brief stops of less than 24 hours, e.g. while traveling through)? Check any that you have been in (each is considered a "YES" answer), or NONE OF THE ABOVE otherwise. *
Required
In the last 14 days, have you traveled internationally or taken a cruise? *
Have you been advised by 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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