screening

Pre-screening Form

Date First Name Last Name Position Student Staff OtherAffiliation FEMASUSAROTHERAgency:

Please answer the following questions accurately. 

In the past week have you had any runny nose, congestion, sore throat, cough, Yes No nausea, vomiting, or diarrhea? Yes NoIn the past week have you had any fever >100.4 or chills? Yes NoHave you had any recent changes in your chronic medical conditions Yes No or medications? Yes NoDo you, or have you had any persistent muscle aches or pains? Yes NoAre you, or have you recently experienced loss of smell or taste? Yes NoHave you taken any fever reducing medication within the past 6 hours Yes No (e.g. Tylenol, Motrin)? Yes NoHave you been exposed (without the use of recommended infection precautions) Yes No to a person with lab confirmed or clinically diagnosed COVID-19 during a period from 48 hours before symptoms of onset until recovery in the past 14 days? Yes NoIs anyone in your household or are you waiting for test results related to COVID-19 Yes No infection? Yes NoAre you, or have you been recently in quarantine or self-isolation for a COVID-19 Yes No exposure or illness? Yes No

The intent of this Pre-screening Form is to make the best attempt to screen for any potential COVID-19 cases. This procedure will assist with making the best-informed decisions possible. Additional medical / deployment considerations should be reviewed by any members that are identified in a group at higher risk for severe illness: (https://www.cdc.gov/coronavirus/2019- ncov/need-extra-precautions/groups-at -higher-risk.html).

Acknowledgement I hereby certify that the above statements / information I have provided are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for benefits or participation.

Administrator staff use only

This section is for use by administrator staff only

Recommendation:

( ) Accept ( ) Reject ( ) Isolate

Date: 04/15/2021  

Time: ________________

Medical Director: ________________________

Coordinator: ___________________________

SUBMIT