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A SCREENING IS CONDUCTED EACH TIME A VISITOR ENTERS THIS FACILITY
If a visitor answers “YES” to any of the following questions, they should be advised to go home, stay away from other people, and contact their
primary care provider or local health authority for further instructions.
DATE TIME NAME
Haveyouexperienced
symptomsofCOVID‐19in
thepast48hours?*
YES NO
Inthepast14days,haveyou
hadcontactwithanyone
confirmedtohaveCOVID‐19or
whohassymptomsofCOVID‐
19?
YES NO
Areyouisolatingor
quarantiningbecauseyoumay
havebeenexposedorareyou
worriedyoumaybesickwith
COVID‐19?
YES NO
Areyoucurrentlywaiting
ontheresultsofaCOVID‐
19test?
YES NO
YES NO YES NO YES
/NO YES NO
YES NO YES NO YES NO YES NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO YES/NO
*SymptomsofCOVID‐19include: feverorchills,cough,shortnessofbreathordifficultybreathing,muscleorbodyaches,headache,newlossoftaste or smell,sorethroat,congestionorrunnynose,
nauseaorvomiting,diarrhea
