Visitor and Staff Screening Tool

NOTE: This tool must be completely filled out for each staff member or visitor entering the building ONCE per day. Only Authorized visitors such as a Medical Director may enter the building. If unsure of the Visitor's status contact the DON or Administrator for permission.

Anyone Entering the building must complete the following questions. All Questions must be completed.

Question Title

* 1. Have you washed your hands or used an alcohol-based hand rub on entry?

Yes

No- Please do Immediately

Question Title

* 2. Have YOU or a FAMILY MEMBER (Living in your home) had any of the following symptoms? (if Yes, Immediately call the DON or Administrator)

Fever

Sore Throat

Cough

New Shortness of Breath

None

Other (please specify)

Question Title

* 3. Have you traveled by air and/or Cruise Ship in the last 14 days?

Yes

Question Title

* 4. Have you had contact with Anyone diagnosed with COVID-19?

Yes (if Yes, Contact DON or Administrator)

Question Title

* 5. Are you Aware No One is to Enter Hall 100 unless they are Assigned to be on the Transition Hall or Escorted by the DON?

Yes

Question Title

* 6. Do you and your family (living in your home) have the basic needs and necessities at this time? Are you aware you may contact Sunny for Needs Assistance?

Yes

N/A Visitor or Vendor

Other (please specify)

Question Title

* 7. Temporal Temperature (if Above 100 Contact the DON or Administrator).

Question Title

* 8. Name

Name

Question Title

* 9. Date/ Time

Date / Time

Date

Time

AM/PM