0000014873 00000 n 0000004165 00000 n 0000012715 00000 n 0000024593 00000 n Phase Two Coronavirus 2019 (COVID-19): Sample Health Screening Tool This document is intended for workplaces and establishments as they implement COVID-19 screening procedures as a universal safeguard to help keep employees, visitors, and patrons safe. Do you have a sore throat? • Please check the Directives, Memorandums and Other Resources page regularly for the most up to date directives. 146 0 obj <> endobj 1 0 obj COVID-19 SCREENING QUESTIONS Please answer the following questions prior to coming to Thomas College. endstream endobj 147 0 obj <>/Metadata 4 0 R/Pages 3 0 R/StructTreeRoot 6 0 R/Type/Catalog/ViewerPreferences<>>> endobj 148 0 obj <. YES or NO, are you currently experiencing any of the following symptoms, that you cannot attribute to another health condition? See ** below. screened for testing for COVID-19. 1. COVID-19 screening questions for access to CDC facilities. COVID-19 Screening Questionnaire . At�8`�cs(�+���^H�K�P+�۟���ƞ�q���c�Z$�sԘ ��X1��!ڑ������0}t�d��� �4�Y���G�����̅`���vGb���-f���O?��iS���u�)�p���M�iׄ=���5��O�z�=�6��N�CC���#�%� n��V��^&��k)G}K��o����b}dF��QO�j�+Q�\&�8ܯݼ&jAM4�-ƚl�׸{;���~HӫsC�,d��jK��fߌk=�k��kKӐ��ep����.hZ�xR�&MҺ��^�}��7Gd§���/��U�|s1�4�)�a�%�8#N�v'i�0 ܆2�Jk�IXi!�i5��9 �5�a�_�I/�E�m��2c �M/���x�1t��y�FRG���N"�Œ�m�*U5��,�GU][4�m"�R֔�UAF�I��8`���Ҡ� Call Telehealth or your health care provider, to find out if you need a test. trailer As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. startxref Following shelter admission or program enrollment, questions should also be re-administered daily for all clients. To prevent the spread of COVID-19, persons attending the program (e.g., participants, parents/guardians, delivery persons, guest speakers) should be pre-screened prior to entering. Therefore, … Do you have a cough? 0000000016 00000 n Saving Lives, Protecting People. F����=��oa���}Λ$~.�Ad>��ʌ�e�t�>.�t�j�,�oǟ����8��4ر���0;�kx��C��5��!ӫ�u�|B��0�^�"�)?��k����A�ECpXs|�1�e�{=z��ʒV��n'U9�67�� ���|��n^���g&�D�D���5�h��6�E[�Ͳ��])̐�{P�[�^O}��\K0��5���)��0'�oI@�C��1�Z}��O���-���Z��qe������xw�Wt�L����q��70�v� �#�u�}Ҝ���M-1�7�my)�0���o�\�8���x��miM�`�і�����'�ܓƔg�2U��V ��d�%����~S���UЋm�H���*�$�q4/�p�"|�^��8��ԀŠ��\������e��� ֩���5.-�E��2�97%�Y��e5��.��tWZ�L�P�C��3����q^�e;�D�x���*��5:�sj��э�=9�FL���h�����J��������0�������1�7W��peA�(�O3 �Eg�I���_-h�\}����� 2. No . PATIENT PRE-SCREENING QUESTIONNAIRE We appreciate your cooperation and patience in helping to keep our patients and staff safe and healthy. 0000012892 00000 n to emergency shelter, transitional housing or engaged with street outreach and may be used in conjunction with a temperature check by staff or the client. 0000008669 00000 n Do you have a loss of smell or taste? See links below for the COVID-19 Screening Checklist on English and French, and other resources: COVID-19 Screening Checklist. 0000029681 00000 n If you are experiencing any symptoms, you should get tested. COVID-19 screening questions Download the alternative format (PDF format, 518 KB, 1 page) Organization: Correctional Service Canada. Ontario Regulation 364/20. 0000009554 00000 n Screening questions relate only to new symptoms or to worsening symptoms related to allergies, chronic or pre-existing conditions. %PDF-1.5 COVID-19 SCREENING FORM As a means of protecting our patients and staff-we are screening all our patients prior to admission to the clinic. ��%�q�Tp�@Q`���]�*ȗR����X�Mq�[��� The worker should report to work. Pre-Appointment COVID-19 Screening Questionnaire To keep our staff and our patients at this practice safe during the COVID-19 pandemic, we are required to update patients’ medical histories and to assess everyone’s COVID-19 status. Skip directly to site content Skip directly to page options Skip directly to A-Z link. 2. What is symptom screening? Please provide accurate answers and help us to help you. If you answered YES to any of these questions, go home & self-isolate. 3 0 obj 0000030211 00000 n 0000009883 00000 n Liste de contrôle pour le déspistage de la COVID-19. contacting your primary health-care provider. Have you or a member of your household traveled by air in the last 14 days? Help us prevent spread Read this carefully. Do you have any of the following respiratory symptoms? CSC is currently taking measures to ensure your safety, the safety of our staff and offenders and limit the risk of infection. Do you have fever (100.4), do you feel warm, or feel chills? Do you have chills? For information about COVID-19 and basic instructions to prevent the spread of disease, visit CDC’s COVID … Please immediately return this form to the person who is hosting you on campus. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> PLEASE ANSWER ALL QUESTIONS: 1. to COVID-19, with this simple screening questionnaire. Your health and well-being are of the upmost importance and we are taking measures to keep the facility/office a safe environment for employees as well as the individuals under our charge and the public. questions, DO NOT ENTER. endobj COVID-19 Screening Checklist for Non-Medical Employers All employees and visitors entering the building should be asked following questions. This tool provides basic information only and contains recommendations for businesses or organizations for COVID-19 screening as per . 0000025160 00000 n xref COVID-19 Stop – Screening Sign. Arrêtez la COVID-19 – Panneau de dépistage. Are you waiting for results from a COVID-19 test or have you tested positive for COVID-19? CDC twenty four seven. Yes . For information about COVID- For information about COVID- 19 and basic instructions to prevent the spread of disease, visit CDC’s COVID-19 website at If you answered NO to all of these question, you have passed and can go to work/attend your activity. Individuals with confirmed or suspected COVID-19 should follow the guidance found here. ��?��k:�xK�`��G��h���$߬�^������|;4���KZ u�~]-.�8�cI8sd��� �'9�:f�,�suU?�}�9=6���1. 0000001282 00000 n COVID-19 Screening Tool for Workplaces (Businesses and Organizations) Version 1 – September 25, 2020 . Have you experienced any of the following symptoms in the past 48 hours? }�rU�+^����2k�[Q2� These questions should be used with . Resources & info. endobj endobj Revised November 25, 2020 Covid-19 Daily Self-Screening Questions Do you have a fever (temperature over 100.4º F or 38º C) without having taken any fever-reducing medications? Before they are allowed to enter buildings, parents or guardians who drive or walk their children to school may be subject to temperature checks and required to answer COVID-19 screening questions. If you answer NO to all questions from 1 through 3, you have passed and can enter the workplace. 5� A SCREENING IS CONDUCTED EACH TIME A VISITOR ENTERS THIS FACILITY Please answer “YES” or “NO” to each question: 1. If you have additional questions about when you can return to work, please email OSSAM@cdc.gov. It is not to be used as a clinical assessment tool or intended to take the place of medical advice, diagnosis or treatment. Date published: 2020-04-01. Patient COVID-19 screening It is important to establish each patient’s COVID-19 status before confirming an appointment. 0000025071 00000 n Media line (for media only): 303-900-2849 CDPHE main website. of Coronavirus in the past 30 days? If it is essential that the patient is accompanied by a parent, carer or comforter, then that person should also be screened at this point. EMPLOYEE COVID-19 SCREENING QUESTIONNAIRE The safety of our employees is our overriding priority. Visitor screening questions This guidance is for clinical and non-clinical staff to enable screening of visitors prior to, or upon entry to a healthcare facility Today or in the last 14 days About the visitor Have you had a high temperature? 0000018810 00000 n • Emphasize respiratory etiquette and hand hygiene by all employees: o Encourage staying home when sick, cough and sneeze etiquette, and hand hygiene. 0000002241 00000 n 146 30 0000050821 00000 n <> YES NO . COVID-19 Screening Questions Symptom and exposure screening questions (check all that apply) Do you have a new onset, or worsening, of any ONE of the following symptoms? <>>> Please follow instructions given by Public Health. 0000050546 00000 n COVID-19 Self-assessment tool by Ontario Ministry of Health. Coronavirus Disease (COVID-19) Workplace Health Screening . You are required by law to self-isolate while awaiting COVID-19 test results or if you have tested positive for COVID-19. Have you had any of the following symptoms: a new, continuous cough or a loss of, or change to, your sense of smell or taste? Call 303-389-1687 or (877) 462-2911. Yes _____ … Thank you so much for your cooperation! ATTACHMENT A-2: San Francisco COVID-19 Health Screening Form for Non-Personnel (November 2, 2020) This handout is for screening clients, visitors and other non-personnel before letting them enter a location or business. You can register for a test . online by clicking ‘Get tested’ on the GNB Coronavirus website, calling Tele-Care 811 or by . Temperature Check: Any reading greater than 100.0°F entry not authorized. It is not intended for people confirmed or suspected COVID-19, including persons under investigation. 0000012537 00000 n If yes, where? If you answer YES to any questions from 1 through 3, you have not passed and you should not enter the workplace (including any outdoor, or partially outdoor, workplaces). If you have additional questions about when you can return to work, please email OSSAM@cdc.gov. When Screening Indicates Fit for Work . 0000029239 00000 n %%EOF 1) In the past 24 hours, have you had any of these symptoms? 0 Entry Screening Novel Coronavirus (COVID-19) Los Angeles County Department of Public Health www.publichealth.lacounty.gov 8/4/2020 Entry Screening (English) - 1 - s Entry screening of employees, volunteers, contract workers or visitors can be part of an organization’s strategy to limit the spread of COVID-19 at their facilities. <<9476B2DB64B2B549936BF2BBB7944AA1>]/Prev 59613/XRefStm 1105>> Colorado Emergency Management. %���� Screening should be done at the beginning and at the end of the workday. Please return home and self-isolate. 0000024222 00000 n this building. _____ Have you traveled to a U.S. City/State with reported cases . YES NO . • Separate employees who become ill at work. • Ask employees reporting to work the following screening questions. What can I do to prevent COVID -19 illnesses in my workplace? Stay at home Colorado guide. %PDF-1.4 %���� Guidance for Daily COVID-19 Symptom Screening of Staff and Guests The Washington State Department of Health recommends employers use this guidance to screen staff and guests (but not customers in retail) at the start of each shift or visit to prevent the spread of COVID-19. 24/7 state-operated facilities include: veterans homes, correctional, behavioral health, developmental … Do you have any of the following symptoms? Have you traveled outside the U.S. in the past 30 days? +mi5����M�,��ׇ���fZgQTc��L�J������jw�hYɒW���*ݘ���ҫ�Z�����Vǵ]m�W�>�����g��] �w��Cx�����szrcKc��s��ƕ.e���k�A��?f�O�{�;�Vp[*7�Bړ°h^VfN�@++����O�X��PJ6.�(44S�}���>)��U�RHb ��.���D�b��������P�|�x�#z�����R�x��һ��tX_I����"�ʎ����Y�u�߭�� COVID-19 Screening Questions . 0000009101 00000 n h�bbbd`b``Ń3���0 3�D z�!�� ��tfX�\BQ��H��������0�L*�.PJ$Va@!���O�������&ps[a^8�9Ι��ϙ��4"� ��?vh��u�g���%i���M���Q3���=GS�Q[?F�Qw���+7��+��Ėd�Z�B?���>d��?��iu��)g'uk�I���% �B `D&��AO�̈�� If yes, where? Do you have a new or unusual headache? Search. Do you have shortness of breath? Please complete, sign and date the following screening questionnaire prior to your appointment. � <> Centers for Disease Control and Prevention. ȥ�*�@j�~�QѬ*-Ʃ�&�6@\�_��i���s߽\s��poI���ʥA�m��ho@zҚ���q��=f}�L4,��u ]��4 Those with symptoms related to pre-existing conditions or allergies can still go to work. cx�;ю�|������� �8=���}=��XHu �%u���s 0000020556 00000 n �#�!bT�� Y z�9c��bfҹT �װ�U�E"�.����L��� x��\ݓ� ����}�2�5���d��WS��6i���Ƀ�ۻ�Ԗ����@�'�]���Ԟ�� ��� ��W����f{*>���W��f{W_/��8���ًo�g?nnw��iw��E����_�x���_x�y�T����^0��-d�DaUU��x�����ǧOXq�/�? stream Submit. 0000006298 00000 n 0000020670 00000 n Leaders should retain all completed forms for 14 days. 0000017045 00000 n COVID-19 Symptom Tracker App Questions COVID-19 Symptom Tracker Mobile App for Apple COVID-19 Symptom Tracker Mobile App for Android/Google •COVID-19 Use of Personal Protective • COVID-19 Symptoms • COVID-19 Related exposure and use of PPE Massachusetts General Hospital Andrew T. Chan predict@mgh.harvard.edu ID: 22013 Global Consortium for Chemosensory Research COVID-19 … If you answered ‘ NO ’ to the above questions, YOU MAY ENTER. 175 0 obj <>stream Therefore, we will need to ask you questions regarding your past and current health. 0000020782 00000 n 2 0 obj Coronavirus 2019 (COVID-19): Sample Health Screening Tool Last Updated: July 1, 2020 Page 1 of 2. COVID-19 Patient Screening Guidance Document are available and updated on the MOH COVID-19 website. the facility. Follow these instructions if the screening you completed indicates that you may be at increased risk for COVID-19. all clients upon admission. h�b``�b``9� ��P3�0p,06q@��b�H~�)2k��-�z�P��ʰ�1�Z���b��q)=� �O"�c,a�5���� �fb`�}7����y8D�a+@� �� Screening questions ... Colorado’s call line for general questions about the novel coronavirus (COVID-19), providing answers in many languages including English, Spanish (Español), Mandarin (普通话) and more. • Fever (100.0°F) or sense of having a fever • Cough for Non-Medical Staff . 0000000896 00000 n Novel Coronavirus (COVID-19) Guidance for Active Screening of Employees at 24/7 State-Operated Facilities The Washington State Department of Health has developed guidance to assist 24/7 state-operated facilities in response to the 2019 novel coronavirus disease (COVID-19) outbreak. WA DOC COVID-19 ACTIVE SCREENING QUESTIONNAIRE This will be updated as the CDC and WA State Health Department’s information on COVID-19 continues to change. 0000001438 00000 n Do you have muscle aches? If yes, stay home. COVID-19: Employee Screening Questions and Guidelines This guidance is intended for screening of employee prior to the start of the workday. 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