covid screening questionnaire pdf

COVID-19 Screening Tool for Workplaces (Businesses and Organizations) Version 1 – September 25, 2020 . I also agree that all the information provided is accurate to the best of my knowledge. Employees can self-screen in advance of work and on site. Are you having shortness of breath or any difficulty breathing? This tool provides basic information only and contains recommendations for businesses or organizations for COVID-19 screening as per . 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. COVID-19 Screening Questionnaire 1. Ontario Regulation 364/20. visitors for onsite meetings should provide this questionnaire to each individual visitor sufficiently in advance so as to minimize inconveniences (travel, expenses, etc.). The following questions are used to screen for COVID-19 before entry into a workplace (business or organization) as per Ontario Regulation 364/20. An official publication of the State of Rhode Island Have you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 Screening Questionnaire and conduct symptom monitoring every day before entering CCAC buildings and facilities. COVID-19 SCREENING QUESTIONNAIRE Date Time Name Birth Year Gender male femaleother B. What the date of your test? Yes No . o Conduct the screening in a format that makes sense for your establishment. ADHA COVID-19 PATIENT SCREENING QUESTIONNAIRE *Indicate Yes or No and provide relevant comments. It is not to be used REV: March 21, 2020 1 . They can also be used for other activities. COVID-19 Screening Questions Symptom and exposure screening questions (check all that apply) Do you have a new onset, or worsening, of any ONE of the following symptoms? What were the results? Visitor Health Screening Questionnaire (COVID-19) At U. S. Steel, safety is our primary core value. Patient Name: Date: Do you have a fever, or have you felt feverish recently? COVID … By … _____ 2.) Guidelines: To prevent the spread of COVID-19 and to reduce the potential risk of exposure to the workforce, please conduct this questionnaire, daily, at designated entry points, prior to accessing the site. 1. Coming to a CCAC campus or facility sick or with symptoms puts the entire college community at an unnecessary risk for spreading the novel coronavirus, the virus that causes COVID–19. Have you or has anyone in your house been tested for COVID-19 coronavirus in the past 14 days? is being investigated or confirmed to be positive for COVID-19? This health screening applies to all trades, suppliers, union reps, employees, etc. No Yes If YES, 1. o It can be a questionnaire, with specific questions to help identify if an individual is reporting possible symptoms of COVID-19 or recent exposure to COVID-19. Yes No • fever > 38°C or think you have a fever or chills • cough • sore throat/ hoarse voice • shortness of breath/ breathing difficulties • loss of taste or smell Newly experienced any of the following symptoms that cannot otherwise be 1..attributed to another condition? Version 6 . o The questionnaire may be administered in various formats (e.g., in-person, over the Have you had close contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE? Do you have chills or repeated shaking with chills? COVID-19 HEALTH SCREENING TOOL. To reduce the risk of spread of COVID-19 in the workplace, employees should be screened prior to entering work. _____ 2. Yes No Yes No Fever or chills Runny/stuffy nose By signing below, I acknowledge that I have filled out this form voluntarily and have a full understanding of the information contained therein. 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