EMPLOYEE COVID-19 SCREENING QUESTIONNAIRE The safety of our employees is our overriding priority. 0000012715 00000 n If you answered ‘ NO ’ to the above questions, YOU MAY ENTER. Individuals with confirmed or suspected COVID-19 should follow the guidance found here. 2. Have you experienced any of the following symptoms in the past 48 hours? 0000012892 00000 n 0000014873 00000 n Temperature Check: Any reading greater than 100.0°F entry not authorized. 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. 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. If yes, stay home. %PDF-1.5 COVID-19 Screening Tool reopeningri.com | health.ri.gov/covid REOPENING RI Recommended tool to screen employees, clients, and/or visitors for symptoms of COVID-19. A SCREENING IS CONDUCTED EACH TIME A VISITOR ENTERS THIS FACILITY Please answer “YES” or “NO” to each question: 1. 0000050546 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 chills? 0000004165 00000 n Colorado Emergency Management. 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? �#�!bT�� Y z�9c��bfҹT �װ�U�E"�.����L��� 0000020670 00000 n 0000000896 00000 n ȥ�*�@j�~�QѬ*-Ʃ�&�6@\�_��i���s߽\s��poI���ʥA�m��ho@zҚ���q��=f}�L4,��u ]��4 If yes, where? Revised November 25, 2020 Therefore, … cx�;ю�|������� �8=���}=��XHu �%u���s Screening should be done at the beginning and at the end of the workday. 0000029681 00000 n 0000009101 00000 n COVID-19 screening questions for access to CDC facilities. 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. Thank you so much for your cooperation! online by clicking ‘Get tested’ on the GNB Coronavirus website, calling Tele-Care 811 or by . 0000009883 00000 n 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�\}����� 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. Do you have a cough? endobj <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Resources & info. 5� If yes, where? h�bbbd`b``Ń3���0 3�D of Coronavirus in the past 30 days? screened for testing for COVID-19. For information about COVID-19 and basic instructions to prevent the spread of disease, visit CDC’s COVID … 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 }�rU�+^����2k�[Q2� xref 0000020782 00000 n this building. Please complete, sign and date the following screening questionnaire prior to your appointment. This tool provides basic information only and contains recommendations for businesses or organizations for COVID-19 screening as per . Centers for Disease Control and Prevention. 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. Are you waiting for results from a COVID-19 test or have you tested positive for COVID-19? Do you have shortness of breath? What can I do to prevent COVID -19 illnesses in my workplace? <> 4 0 obj � 146 30 • Separate employees who become ill at work. 0000050821 00000 n 1 0 obj Stay at home Colorado guide. Do you have a sore throat? 0000024222 00000 n 2 0 obj You are required by law to self-isolate while awaiting COVID-19 test results or if you have tested positive for COVID-19. No . Please return home and self-isolate. trailer COVID-19: Employee Screening Questions and Guidelines This guidance is intended for screening of employee prior to the start of the workday. Media line (for media only): 303-900-2849 CDPHE main website. 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. PLEASE ANSWER ALL QUESTIONS: 1. 0000002241 00000 n 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�/�? If you have additional questions about when you can return to work, please email OSSAM@cdc.gov. %���� Yes _____ … Please immediately return this form to the person who is hosting you on campus. 0000020556 00000 n COVID-19 screening questions Download the alternative format (PDF format, 518 KB, 1 page) Organization: Correctional Service Canada. Yes . • Ask employees reporting to work the following screening questions. • Emphasize respiratory etiquette and hand hygiene by all employees: o Encourage staying home when sick, cough and sneeze etiquette, and hand hygiene. to COVID-19, with this simple screening questionnaire. If you have additional questions about when you can return to work, please email OSSAM@cdc.gov. %%EOF Patient COVID-19 screening It is important to establish each patient’s COVID-19 status before confirming an appointment. questions, DO NOT ENTER. Those with symptoms related to pre-existing conditions or allergies can still go to work. 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. 0000001105 00000 n _____ Have you traveled to a U.S. City/State with reported cases . 0000000016 00000 n 1. 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�̈�� Do you have any of the following respiratory symptoms? COVID-19 Screening Questionnaire . 0000009554 00000 n Search. YES or NO, are you currently experiencing any of the following symptoms, that you cannot attribute to another health condition? endstream endobj 174 0 obj <>/Filter/FlateDecode/Index[6 140]/Length 27/Size 146/Type/XRef/W[1 1 1]>>stream endobj startxref Do you have any of the following symptoms? +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�߭�� See links below for the COVID-19 Screening Checklist on English and French, and other resources: COVID-19 Screening Checklist. 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. 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). contacting your primary health-care provider. What is symptom screening? Submit. endstream endobj 147 0 obj <>/Metadata 4 0 R/Pages 3 0 R/StructTreeRoot 6 0 R/Type/Catalog/ViewerPreferences<>>> endobj 148 0 obj <. endobj CUSFF/NAVNORTH COVID-19 Screening Questionnaire (V2020.07.16) 1. 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. Do you have a loss of smell or taste? 146 0 obj <> endobj Arrêtez la COVID-19 – Panneau de dépistage. for Non-Medical Staff . COVID-19 Screening Checklist for Non-Medical Employers All employees and visitors entering the building should be asked following questions. stream Screening questions relate only to new symptoms or to worsening symptoms related to allergies, chronic or pre-existing conditions. Please follow instructions given by Public Health. See ** below. 1) In the past 24 hours, have you had any of these symptoms? 0000030211 00000 n Following shelter admission or program enrollment, questions should also be re-administered daily for all clients. 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+@� �� YES NO . Ontario Regulation 364/20. COVID-19 Screening Tool for Workplaces (Businesses and Organizations) Version 1 – September 25, 2020 . 0000024593 00000 n Call Telehealth or your health care provider, to find out if you need a test. 3 0 obj 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? Saving Lives, Protecting People. 0000017045 00000 n CSC is currently taking measures to ensure your safety, the safety of our staff and offenders and limit the risk of infection. Therefore, we will need to ask you questions regarding your past and current health. 0000025071 00000 n Date published: 2020-04-01. • Please check the Directives, Memorandums and Other Resources page regularly for the most up to date directives. Traveled outside the U.S. in the last 14 days limit the risk of infection accurate and. A means of protecting our patients and staff-we are screening all our patients prior to to! 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