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* 1. Date

Date

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* 2. First Name, Last Name

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* 3. Are you a PCA/ HHA, LPN or RN?

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* 4. Do you have a temperature of 100 or higher or upper respiratory symptoms such as a cough or sore throat? 

(If yes- please call out using regular call out procedures and obtain medical clearance prior to returning to work.)

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* 5. Have you traveled to a country for which the CDC has issued a Level 2 or 3 travel designation within the last 14 days?

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* 6. Have you been in contact with a confirmed COVID 19 patient or person under investigation for COVID 19? 
  
(If yes- please call out using regular call out procedure and obtain medical clearance prior to returning to work.)

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* 7. As per applicable state and/or federal regulations and the associated agency policies, caregivers are required to report pertaining to “changes in patient condition”. 

All agency nurses and aides must obtain the following information from their patients:
1. Ask/observe patient’s condition regarding upper respiratory symptoms (e.g., cough, sore throat, fever, or shortness of breath);
2. Ask the patient, “Have you traveled to a country for which the CDC has issued a Level 2 or 3 travel designation within the last 14 days?”; and
3. Ask the patient, “Have you had contact with any Persons Under Investigation (PUIs) for COVID-19 within the last 14 days, OR with anyone with known COVID-19?”

If the patient answers “Yes” to questions 2 or 3, but does not report, or upon observation does not show signs of, respiratory infection symptoms, the homecare nurse/aide should contact Complete Home Care Services (718) 528-5493 and inform us of the patient’s risk factors (based on the responses to questions 2 and 3) and report if there are changes in the patient’s condition based on observation, patient self-report and vital signs to receive guidance.  

Please check yes if you have read and understand caregiver's responsibility to report on changes in patient condition, specifically as it relates to COVID-19.

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