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** Name* First Last Date* Date Format: MM slash DD slash YYYY 1. DO YOU HAVE ANY SIGNS OR SYMPTOMS OF RESPIRATORY INFECTION? (check all that apply)* Unexplained cough or tightness of chest Fever or have taken fever reducing medicine in the last 24 hours Shortness of Breath Sore Throat No, I am not experiencing any of the above symptoms My current Temperature in Fahrenheit is:*Temperature must be less than 100 degrees to continue to work.2. My current temperature is:*Select onedid not take temperature100 degrees or aboveless than 100 degreesSignature*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.
