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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
symptomsofCOVID19in
thepast48hours?*
YES NO
Inthepast14days,haveyou
hadcontactwithanyone
confirmedtohaveCOVID19or
whohassymptomsofCOVID
19?
YES NO
Areyouisolatingor
quarantiningbecauseyoumay
havebeenexposedorareyou
worriedyoumaybesickwith
COVID19?
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
*SymptomsofCOVID19include: feverorchills,cough,shortnessofbreathordifficultybreathing,muscleorbodyaches,headache,newlossoftaste or smell,sorethroat,congestionorrunnynose,
nauseaorvomiting,diarrhea