Fillable US Prisons VISITOR/VOLUNTEER/CONTRACTOR COVID-19 SCREENING TOOL

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US Prisons VISITOR/VOLUNTEER/CONTRACTOR COVID-19 SCREENING TOOL

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VISITOR/VOLUNTEER/CONTRACTOR COVID-19 SCREENING TOOL
3/13/20, Version 1.0
1. Have you…….
Yes No
a. Traveled from or through, any of the following locations identified by the
CDC as increasing epidemiologic risk for COVID-19 within the last 14
days?
China, Iran, South Korea, Italy, Japan
Yes No
b. Had close contact with anyone diagnosed with the COVID-19 illness
within the last 14 days?
2. Do you currently have a …………
Yes No
a. Fever or Chills
Yes No
b. Cough
Yes No
c. Shortness of Breath
3. Perform a temperature check ______
◦
F Method: oral / forehead (temporal) / tympanic
*Staff see instruction sheet for screening form.
Purpose of Visit (Circle one):
Attorney-legal / Contractor / Volunteer
Social (visiting an inmate) – Inmate name/reg. number ______________________________
Other - ______________________________________________________________________
Visitor Name (Last, First): _____________________________________________________
Date: ______________________________________________________________________
Institution: _________________________________________________________________
VISITOR/VOLUNTEER/CONTRACTOR COVID-19 SCREENING TOOL
3/13/20, Version 1.0
Instructions for staff:
The BOP staff member will provide the COVID-19 Screening Tool to all persons entering the
lobby (visitors, volunteers, contractors, legal visits, etc.), ask each person to complete
questions 1. a-b and 2. a-c. A qualified health care staff member will complete the
temperature check.
If answers to all the questions are No, and there are no obvious signs of respiratory infection,
e.g. frequent coughing, and temperature is < 100.4
○
F, follow usual procedures.
Social visitors: If answers to any of the questions are YES, or if the person has a temperature ≥
100.4
○
F (oral), or if the person has obvious signs of a respiratory illness, ask social visitors to
wait in a separate area (6 feet from others or outside), and contact the Operations Lieutenant
and/or Institution Duty Officer (IDO), for further direction to the visitor(s). The IDO or
Operations Lieutenant should deny visitation and not allow entry into the institution.
Attorney/Contractor/Volunteer: If answers to any of the questions are YES, or if the person
has a temperature ≥ 100.4
◦
F (oral), or if the person has obvious signs of a respiratory illness,
they should not be allowed entry to the institution.
In the case of an attorney / legal visitor who answers yes to any of the questions, decisions
may be made on a case-by-case basis with approval at the local level and confidential legal
calls will be allowed.
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US Prisons VISITORVOLUNTEERCONTRACTOR COVID-19 SCREENING TOOL

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Completed 26 March 2020

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