Daily Resident / Visitor Health Screen

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* 1. Date

Date / Time

Date

Time

AM/PM

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* 2. Resident or Visitor's Name

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* 3. Current Temperature

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* 4. Is the temperature greater than 99.9F

Yes

No

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* 5. Does resident/visitor have a cough that is new or an existing cough that is worsening?

Yes

No

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* 6. Does resident/visitor have shortness of breath that is new?

Yes

No

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* 7. Does resident/visitor have any additional concerning symptoms such as sore throat, frequent sneezing, runny nose, unusual body aches, or chills?

No - nothing new

Yes - sneezing / runny nose

Yes - sore throat

Yes - unusual body aches / chills

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* 8. If you answered yes to any of the above yes/no questions do not allow the visitor to enter the home until you speak with a nursing supervisor for PDHH. If you answered yes to any of the above yes/no questions for a resident, please take them to their room and notify the nurse supervisor for further instructions.

Resident / Visitor Passed Health Screen

I called the nursing supervisor - visitor denied entry

I called the nursing supervisor - resident taken to room

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* 9. Staff name who completed the survey