COVID-19 Health Screen
Must be completed before every shift.
*
1.
Date
(Required.)
*
2.
What is your full name?
(Required.)
*
3.
Do you now or in the past 48 hours had a temperature of 99.9F or greater?
(Required.)
Yes
No
Other (please specify)
*
4.
Do you have a cough? (new onset, or worsening in the past 48 hours?)
(Required.)
Yes
I always have a cough, this is nothing new for me
No
Comment
*
5.
Are you short of breath? (New onset, or worsening in the past 48 hours.)
(Required.)
Yes
I am always short of breath - this is normal for me.
No
comment
*
6.
Have you been in direct contact with anyone who has the above symptoms or has been diagnosed with COVID - 19?
(Required.)
Yes
No
comment
*
7.
My answers are truthful and answered to the best of my ability.
(Required.)
Yes
No
*
8.
I understand that If I answered yes to questions 3-6 that I need to call and speak with the PDHH nursing supervisor before the start of my shift.
(Required.)
Yes
No
*
9.
I understand that I am expected to wear a mask at all times when I am working in a clients home. (Removal of mask for eating/drinking/fresh air break must be done in a room separate from clients).
(Required.)
Yes
No
10.
please add any additional information or further explain answers that may need further clarification.
