Fillable Coronavirus (COVID-19) Self-Monitoring Information You are receiving this (Tulsa Community College)

Fill Online, Printable, Fillable, Blank Coronavirus (COVID-19) Self-Monitoring Information You are receiving this (Tulsa Community College) Form

Use Fill to complete blank online TULSA COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Coronavirus (COVID-19) Self-Monitoring Information You are receiving this (Tulsa Community College)

On average this form takes 18 minutes to complete

The Coronavirus (COVID-19) Self-Monitoring Information You are receiving this (Tulsa Community College) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Tulsa Community College

BROWSE TULSA COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
3.03.2020
Coronavirus (COVID-19) Self-Monitoring Information
You are receiving this document because you recently traveled in a country for which the Centers for Disease
Control and Prevention (CDC) has issued a travel advisory due to the spread of a new (novel) coronavirus which
causes respiratory illness (COVID-19).
Guidance for persons being monitored for coronavirus
This guidance is to help you closely monitor your health for up to 14 days because you may have been exposed
to coronavirus. This does NOT mean that you will get sick with coronavirus. It is very important for you to monitor
your health so that you can be taken care of and treated quickly if you do get sick. Based on what is known from
other coronavirus infections, 14 days is the longest time between when you were last exposed to coronavirus and
when symptoms begin.
W
hat are the signs and symptoms of coronavirus?
The most common symptoms of coronavirus are fever and cough. Some people also report difficulty breathing,
more rarely sore throat, muscle aches, and abdominal discomfort. These symptoms can also be due to many
other illnesses. If you develop a fever or any symptoms, it doesn’t mean you have coronavirus.
How should you monitor your health during this time period?
Use the reverse side of this form to record your temperature and possible symptoms. Record this information
twice per day and send to Kurt Nielson at TCCemergencymanagement@tulsacc.edu
P
ractice protective and careful measures during this time period.
• You are not under quarantine or isolation, but you should avoid contact with others and try to isolate
yourself to keep the risk of secondary transmission at its lowest.
• Cover your mouth and nose with a tissue or sleeve when coughing or sneezing.
• Clean your hands often using soap and water, or a hand sanitizer that is 60%-95% alcohol.
• Limit travel on public transportation.
I
nstructions for monitoring your temperature and symptoms:
1. Take your temperature orally (by mouth) with a digital thermometer 2 times a day:
o Once in the morning
o Once in the evening.
2. Write down your temperature on the form twice a day, every day.
3. If you forget to take your temperature, take it as soon as you remember.
4. Mark if you have any of the symptoms of novel coronavirus listed on the form.
W
hat should I do if I become ill during this monitoring period?
DO NOT GO to a clinic or hospital without first calling your primary care provider, or see the BCBS Telemedicine
Guidance on MyTCC. If your symptoms are mild, it is possible that you may be able to remain at home. If it is
determined that you need medical attention, the clinic or health provider will provide guidance on how best to
receive medical treatment.
I
f you feel your symptoms are at EMERGENCY LEVELS i.e. shortness of breath, fever over 102°F, chest pain
etc., that cannot wait until the morning, call 911 and explain that you are being monitored for potential exposure to
coronavirus and need emergency medical care.
14-day incubation period observations
Take your temperature twice a day, in the morning and in the evening, and write it down. Mark if you have
any of the symptoms: circle ‘Y’ for Yes and ‘N’ for No. Don’t leave any spaces blank.
N
AME____________________________________________ DATE STARTED___________________________________
DATE TIME Temperature Cough
Fatigue
or aches
Shortness
of Breath
Diarrhea Chills
1
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
2
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
3
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
4
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
5
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
6
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
7
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
8
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
9
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
10
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
11
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
12
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
13
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
14
AM
Y N Y N Y N Y N Y N
PM
Y N Y N Y N Y N Y N
A TCC representative
will contact you at various times to help track your progress.
*
The attached forms are provided by the Centers for Disease Control and Prevention for patients who are
under public health monitoring. They are being provided to you out of an abundance of caution to use to
protect yourself while at home.
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Coronavirus (COVID-19) Self-Monitoring Information You are receiving this (Tulsa Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document