COVID-19 Screening Form






    Yes

    CoughShortness of breath

    FeverRepeated shaking with chillsHeadcheNew loss of test or smellDiarrheaChillsMuscle PainSore throatVomiting

    • If YES to any, restrict them from entering the building.

    • If NO to all, proceed to question #4.

    • If YES, please wait for our direction before entering our building.

    • if NO, Proceed to step 3B.

    If YES, have you worked with the person who has confirmed COVID-19?

    • If YES, please wear PPE including mask and gloves when you come to our facility. We will give you a gown before any contact with residents. Also, please proceed to step 4.

    • If NO, Proceed to step 4.

    Wash your hands or use ABHR throughout your time in the building.Do not shake hands with, touch or hug individuals during your visit.Wear a facemask while in the buiding & restrict your visit to the residents room or other location designed by the facility.