Please complete the screening questions in this survey prior to each shift. If you have questions, please contact your supervisor.
Revised 7/9/2020

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* 1. Date:

Date

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* 2. Staff first name:

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* 3. Staff last name:

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* 5. Record current temperature (in degrees Fahrenheit):

COVID-19 SYMPTOMS:
Any ONE of the following that is not typical for you:
· Fever greater than or equal to 100.4°F (38°C)
(without the use of fever-reducing medications)
· Chills
· Congestion or runny nose
· Cough
· Diarrhea
· Fatigue
· Headache
· Muscle or body aches
· Nausea or vomiting
· New loss of taste or smell
· Shortness of breath or difficulty breathing
· Sore throat

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* 6. Are you currently experiencing any COVID-19 symptoms listed above? 

IF YOU ANSWER YES, DO NOT WORK

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* 7. In the last 14 days, have you had known close contact (within 6 feet for a cumulative total of 15 minutes or more within 24 hour period) with anyone who has tested positive for COVID-19?

If YES, you may work but you must MASK.

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* 8. In the last 14 days, have you provided care without wearing proper PPE for a patient with symptoms of COVID-19 OR who tested positive for COVID-19?

If YES, you may work but you must MASK.

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* 9. In the past 14 days, have you had close contact with a person visibly sick with COVID-19 symptoms or who says they are sick with COVID-19 symptoms?

If YES, you may work but you must MASK.

If you answered YES to any of the questions, contact your supervisor for guidance.

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