Staff Screening Questionnaire

Please complete and submit the form below. It is a questionnaire that can be completed in approximately one minute. All fields require a response.

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First Name *

Last Name *

Veterans Center *

In response to concerns regarding COVID-19 and other infectious viruses, and in accordance with guidance issued by CMS and the CDC, our facility has implemented screening protocol of staff for signs and/or symptoms of infection.

All staff shall be screened at the beginning of their shift for fever and signs/symptoms.
The employee’s temperature shall be taken and recorded, along with the absence of shortness of breath, new or worsening change in cough, and sore throat.
If the employee is ill, have them put on a facemask and self-isolate at home. Employee shall be fever free for 24 hours without the use of medications before returning to work.

Questions

1. In the last 14 days, have you had contact with someone with a confirmed case of COVID-19, or under investigation for COVID-19, or who is ill with a respiratory illness? *

2. Do you have signs of a respiratory infection, such as fever, cough, shortness of breath, or a sore throat? *

3. Have you traveled internationally or to another state in the last 14 days or live in a community where the spread of COVID-19 is occurring? *

4. Do you agree to perform hand hygiene frequently or as needed and to wear PPE as directed or indicated? *

5. Are you employed with a second job? If so, where and what position? *

Enter question 5 response here if applicable:

Signs / Symptoms

Indicate below if you have experienced any of the following signs or symptoms in the last 14 days or if you are currently experiencing them.

1. Fever greater than 100.4 F *

2. Subjective Fever (felt feverish) *

3. Chills *

4. Headache *

5. Muscle Aches *

6. Runny Nose *

7. Cough (new onset or worsening of chronic cough) *

8. Shortness of Breath *

9. Nausea or Vomiting *

10. Diarrhea/Abdominal Pain *

Certification

Please type your name in full as your signature to this form, and enter today's date.
“I hereby certify that:
(1) I am the person named herein above, and that this form has not been completed or submitted on my behalf by a third party;
(2) the information contained in this form is true, complete, and correct to the best of my knowledge and belief; and
(3) any misrepresentation or omission of a material fact with respect to the foregoing constitutes a false statement and may subject me to disciplinary action for misconduct up to and including discharge.”

Signature *

Date *

Time *

Last Modified on Nov 25, 2020