Employee COVID-19 Self Screening Questionnaire

There has been new guidance from the CDC on possible symptoms. Please review the questions carefully and answer appropriately.

1) Any of combination the following symptoms in the last 24 hours: *

Yes

No

Fever (usually 100.4 or higher)

Muscle pain

Headache

Sore throat

New loss of taste or smell

Cough

Dehydration (dry lips and mouth, not urinating much, sunken eyes

Signs of low blood pressure (too weak to stand, dizziness, lightheaded, feeling cold, pale, clammy skin)

New or worsening seizures

Slurred speech or difficulty speaking (new or worsening)

Find it very difficult to wake up

New disorientation (acting confused)

Extreme difficulty in breathing (such as gasping for air, being unable to talking without catching your breath, sever wheezing, nostrils flaring)

Severe and constant pain or pressure in the chest

Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone

Repeated shaking with chills

To comply with safety standards to protect you, the client, and involved others, we require that employees, clients, and those who reside with the client are Covid-19 symptom-free. Please complete and submit this form on days that clients and employees work together in person.

You must answer “NO” to all the questions in this questionnaire for an employee to work with the H.A.T.C.H. client.

If you answered “Yes” to any of the questions, please DO NOT report to work. You should:

Contact the client, family, facility, or supportive living staff to let them know that you will be unable to work.
Contact your doctor and follow their health orders. If they have determined that you or someone in your household is Covid-19 positive, you should do the following:
Self- quarantine for at least 10 days from the date on which you first experienced any of the above symptoms ; AND
Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you: *

Yes

No

Been in contact with someone who was diagnosed with COVID-19?

Been in close contact with someone who had COVID-19 symptoms ?

Traveled internationally?

If you answered “Yes” to any part of question two, please DO NOT report to work if you are doing in-person services. You should self-quarantine for at least 10 days.

3) Are you wearing a properly fitting mask that covers both your nose and your mouth? *

Yes No

Please contact the H.A.T.C.H. office if you need additional personal protective equipment.

Are there any chronic conditions that present as similar symptoms such as a headaches, chills, or a cough? We are checking for new or unusual symptoms directly related to COVID-19. Please contact H.A.T.C.H. to discuss further if needed. *

Yes No

4) Today's body temperature: *

I certify to the best of my knowledge; this information is accurate.

Signature *

Clear

Name *

First Name Last Name

Date *

Month Day Year