COVID-19 ACTIVE SCREENING QUESTIONNAIRE
This will be updated as the CDC and North Carolina State Health Department’s information on COVID-19 continues to change. Your health and well-being are of the upmost importance and we are taking measures to keep the facility/office a safe environment for employees as well as the individuals under our charge and the public. Therefore, anyone coming into the facility/office will be screened and part of our screening process will include taking their temperature and asking the following questions.
If the individual answers YES to any of the questions they will not be allowed into the facility/office unless determined otherwise by the designated owner/operator. *However, the following guidelines must apply: As long as they remain asymptomatic; self-monitor symptoms as outlined in the guidance; and wear a surgical mask at entry and at all times while on facility grounds.
Client's Name
First Name
Last Name
Within the last 14-days, have you experienced a new cough that you cannot attribute to another health condition?
Yes
No
Within the last 14-days, have you experienced new shortness of breath that you cannot attribute to another health condition?
Yes
No
Within the last 14-days, have you experienced a new sore throat that you cannot attribute to another health condition?
Yes
No
Within the last 14-days, have you experienced new muscle aches that you cannot attribute to another health condition or a specific activity such as physical exercise?
Yes
No
Within the last 14-days, have you had a temperature at or above 100.4° or the sense of having a fever?
Yes
No
Within the last 14 days, have you had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19?* (Note: Close contact is defined as within 6 feet for more than 10 consecutive minutes)
Yes
No
I attest that this information is truthful and valid.
Client's Signature
Clear
Legal Guardian Signature (if under 18 years of age)
Clear
DateTime
Submit
Print Form
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