COVID-19 Staff/Visitor Screening Tool

Please complete and submit the following COVID-19 screening tool each day.

Identification

This screening is being completed for a:

First Name

Last Name

Phone Number

Estimated Duration of Visit

Room

Screening Questions

1. In the last [5, 10] days have you experienced any of these symptoms?

Fever and/or chills

Cough or barking cough (croup)

Shortness of breath

Decrease or loss of taste or smell

2. In the last [5, 10] days have you experienced any of these symptoms?

Sore throat or difficulty swallowing

Runny or stuffy/congested nose

Headache

Extreme tiredness

Muscle aches or joint pain

Nausea, vomiting and/or diarrhea

3. In the last [5, 10] days have you tested positive for COVID-19?

Yes

No

4. Do any of the following apply?

Yes

No

5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

No

6. Do any of the following apply?

Yes

No