COVID-19 SCREENING RESOURCE

Pre-Screening Questionnaire

DAILY COVID-19 SCREENING QUESTONAIRE **THIS FORM MUST BE COMPLETED BY EVERY PERSON WHO ENTERS THE ROOM EACH DAY**
  • Date Format: MM slash DD slash YYYY
  • Temperature must be less than 100 degrees to continue to work.
  • By signing, I confirm that I have answered the above questions honestly and that if I develop signs or symptoms of respiratory illness, including fever, cough, shortness of breath, or sore throat that I will contact the person in charge.