EHS Client COVID-19 Checklist

Please submit this checklist BEFORE meeting with an EHS client.

If the answer is YES to a symptom in question #3 OR YES to two or more symptoms in question #4, and/or the client has a temperature of 100.4 or higher, please do not meet with the client. Cancel the meeting and reschedule. Advise the client to self-isolate at home and to contact their primary care physician's office for direction. This survey is to be completed for each home visit and include the names of all that will be participating in the meeting. EXCEPTION for #6: If answered "yes", you may continue to meet with the client IF they have received the COVID-19 vaccine, and it has been at least 2 weeks since their final vaccine. Thank you.

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* 1. Please select the COUNTY where you will be meeting with the client.

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* 2. What are the clients' names?

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* 3. Ask the client the following questions:
IIn the past 24 hours have you experienced any of the following symptoms not explained by a known medical or physical condition?

	No	Yes
Fever	Fever No	Fever Yes
Uncontrolled cough	Uncontrolled cough No	Uncontrolled cough Yes
Shortness of breath	Shortness of breath No	Shortness of breath Yes

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* 4. In the past 24 hours have you experienced any TWO of the following symptoms not explained by a known medical or physical condition?

	No	Yes
Loss of taste of smell	Loss of taste of smell No	Loss of taste of smell Yes
Muscle pain	Muscle pain No	Muscle pain Yes
Sore throat	Sore throat No	Sore throat Yes
Severe headache	Severe headache No	Severe headache Yes
Diarrhea	Diarrhea No	Diarrhea Yes
Vomiting	Vomiting No	Vomiting Yes
Abdominal pain	Abdominal pain No	Abdominal pain Yes

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* 5. What are the current temperatures of anyone that will be present at the home visit today? (##.#)

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* 6. Has anyone that will be at the home visit had close contact in the last 14 days with an individual diagnosed with COVID-19? (The CDC defines close contact as being within 6 feet of an infected person for 15 minutes or more.)

Yes

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* 7. Have you been directed or told by anyone to self-isolate or self-quarantine?

Yes

EHS Client COVID-19 Checklist

Please submit this checklist BEFORE meeting with an EHS client.

Question Title

* 1. Please select the COUNTY where you will be meeting with the client.

Question Title

* 2. What are the clients' names?

Question Title

* 3. Ask the client the following questions:IIn the past 24 hours have you experienced any of the following symptoms not explained by a known medical or physical condition?

Question Title

* 4. In the past 24 hours have you experienced any TWO of the following symptoms not explained by a known medical or physical condition?

Question Title

* 5. What are the current temperatures of anyone that will be present at the home visit today? (##.#)

Question Title

* 6. Has anyone that will be at the home visit had close contact in the last 14 days with an individual diagnosed with COVID-19? (The CDC defines close contact as being within 6 feet of an infected person for 15 minutes or more.)

Question Title

* 7. Have you been directed or told by anyone to self-isolate or self-quarantine?

* 3. Ask the client the following questions:
IIn the past 24 hours have you experienced any of the following symptoms not explained by a known medical or physical condition?