Employee COVID-19 Self Screening Questionnaire

COVID-19 Self Screening Questionnaire

The safety of our staff and patients is our overriding priority. As the coronavirus (COVID-19) pandemic continues, Hospicare will adhere to the most current local, state, and/or federal guidelines and best practice regarding staff and patient safety to reduce the risk of exposure to COVID-19. The information collected on this form will be used to determine only whether you may be infected with, or pose a high risk of having been exposed to COVID-19 . The information on this form will be maintained as confidential. Any questions should be directed to your supervisor
Person Completing This Form
Person Being Screened (if other than person completing form)*
First and last name
Contact information*
Email and/or phone
Date*

MonthDayYear
Date
I am a:*

Staff memberVolunteerPatient - communityPatient - residenceCaregiver or Visitor - community patientCaregiver or Visitor - residence patientVendor/other
Hospicare Staff: The New York State Department of Health has mandated that staff must be self monitoring and Hospicare is requiring staff to complete and submit this questionnaire prior to starting work, and at the end of each work day. This questionnaire must be completed by all staff entering the building (for any reason), having patient (actual or potential) contact, and staff who will be having interaction with the community for Hospicare purposes.

If you answer yes to any of the questions (with the exception of the certification question) immediately contact your supervisor for further guidance. Please do not enter any Hospicare building or have any patient or community contact until you have received clearance to do so.

* Questionnaire completion required prior to starting work and at the end of each work day.

In the last 14 days have you:*

	Yes	No
Tested positive for COVID-19?
Been in close contact with someone who had COVID-19 symptoms or tested positive? (Close contact meaning being within 6 feet of someone for more than 10 minutes.)
Experienced ANY of the following symptoms: fever (100F/37.8C or greater), cough, shortness of breath, difficulty breathing, sore throat, fatigue, new loss of taste or smell, chills, congestion, runny nose, headache, muscle or body aches, nausea, vomiting or diarrhea?

If you answered “Yes” to any of the questions above, please contact your supervisor.
What is your current temperature*
If greater that 100F or 37.8C, contact your supervisor
I hereby certify that the responses provided above are true and accurate to the best of my knowledge.*

YesNo
Should be Empty: