Must be completed before every shift.  

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* 1. Date

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* 2. What is your full name?

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* 3. Do you now or in the past 48 hours  had a temperature of 99.9F or greater?

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* 4. Do you have a cough?  (new onset, or worsening in the past 48 hours?) 

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* 5. Are you short of breath?  (New onset, or worsening in the past 48 hours.)

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* 6. Have you been in direct contact with anyone who has the above symptoms or has been diagnoses with COVID - 19?

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* 7. My answers are truthful and answered to the best of my ability.

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* 8. I understand that If I answered yes to questions 3-6 that I need to call and speak with the PDHH nursing supervisor before the start of my shift.

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* 9. I understand that I am expected to wear a mask when I am within 6 feet of my client.  

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* 10. please add any additional information or further explain answers that may need further clarification. 

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