COVID-19 Health Screen Must be completed before every shift. Question Title * 1. Date Question Title * 2. What is your full name? Question Title * 3. Do you now or in the past 48 hours had a temperature of 99.9F or greater? Yes No Other (please specify) Question Title * 4. Do you have a cough? (new onset, or worsening in the past 48 hours?) Yes I always have a cough, this is nothing new for me No Comment Question Title * 5. Are you short of breath? (New onset, or worsening in the past 48 hours.) Yes I am always short of breath - this is normal for me. No comment Question Title * 6. Have you been in direct contact with anyone who has the above symptoms or has been diagnosed with COVID - 19? Yes No comment Question Title * 7. My answers are truthful and answered to the best of my ability. Yes No Question Title * 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. Yes No Question Title * 9. I understand that I am expected to wear a mask at all times when I am working in a clients home. (Removal of mask for eating/drinking/fresh air break must be done in a room separate from clients). Yes No Question Title * 10. please add any additional information or further explain answers that may need further clarification. DONE
