Client and Household Members COVID-19 Self- Screening Questionnaire

Client and Household Members' COVID-19 Self- Screening Questionnaire

Please submit one form per household. Form must be completed on a smart phone, a tablet or computer for digital signature.
To comply with safety standards to protect clients, employees, and involved others, we require that employees, clients, and those who reside with the client are symptom-free. Please complete and submit this form on days that clients and employees work together.

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 answer “YES” to any of the questions, please DO NOT allow the H.A.T.C.H. employee to enter the client's home or to have them work with the client.

If anyone who resides with the client experiences any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND H.A.T.C.H.

1) Has anyone in the household had any of the following symptoms in the last 24 hours? *

Yes

Cough

Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

Yes

Fever (usually 100.4 or higher)

Chills

Repeated shaking with chills

Muscle pain

Headache

Sore throat

New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come into work. You should:
- 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

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

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

Traveled internationally or taken a cruise

3)Today's body temperature of client and other household members (separate by commas): *
If you answered “Yes” to any part of question two, please DO NOT allow the H.A.T.C.H. employee to come into work. You should self-quarantine for at least 14 days.
Are there any chronic conditions within the household that present as similar symptoms such as a headaches, chills, or a cough? We are checking for new or unusual symptoms. Please contact H.A.T.C.H. to discuss further if needed. *

Yes No
I certify to the best of my knowledge; this information is accurate.
Signature (must be signed by using a smart phone or tablet) *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

Client and Household Members' COVID-19 Self- Screening Questionnaire