RKGC Volunteer Health Screening Questionnaire
Please complete the following questionnaire before each volunteer shift
Name
*
First Name
Last Name
Date
-
Day
-
Month
Year
Date
In the last 72 hours, have you or any member of your household had any of the following COVID-19 symptoms: fever (100F or higher), felt feverish or had chills, a cough, sore throat, muscle aches, difficulty breathing, or new loss of taste or smell?
*
Option 1: No (or "Yes, but I was cleared by a qualified medical professional to work")
Option 2: Yes
In the last 24 hours have you or any member of your household had gastrointestinal distress (nausea, vomiting, diarrhea), fatigue, headache, runny nose or congestion, or any other sign of illness?
*
Option 1: No
Option 2: Yes
In the last 10 days, has anyone in your household been advised to be tested due to a known/suspected exposure to COVID-19 or be advised or directed to quarantine or self-isolate due to COVID-19
*
Option 1: No (or "Yes, but I was cleared by a qualified medical professional to work")
Option 2: Yes
In the last 10 days, has anyone in your household traveled to a restricted area or attended a gathering (indoor or outdoor) where attendance exceeded, or was otherwise not in compliance with, recommended guidance? Per the Governor's COVID-19 Order #54, indoor gatherings at private residences are limited to 10 people and outdoor gatherings at private residences are limited to 25 people.
*
Option 1: No
Option 2: Yes
Please take your temperature. Is your temperature at or above 100 degrees Fahrenheit?
*
Option 1: No
Option 2: Yes
Are you cleared to volunteer today?
*
Yes (I answered all "Option 1" above)
No (I did not answer all "Option 1" above)
Signature
*
Email
example@example.com
Submit
Should be Empty: