COVID-19 Screening Questions
We are taking extra precautions to keep you and our staff safe. All incoming clients and visitors must complete the following screening questionnaire to limit transmission of COVID-19. Thank you for your patience and support.
Date of visit to NCCC
Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19?
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?:
Do you currently have any of the following symptoms?:
New and persistent cough
Shortness of breath or any difficulty breathing
Pink eye (conjunctivitis)
Decrease or loss of sense of taste or smell
Unexplained fatigue, malaise, muscle aches (myalgias)
Runny nose/nasal congestion without other known cause
Nausea/vomiting, diarrhea, abdominal pain
None of the above
By typing your name in the "Signature" space above, you certify that your answers are true and complete to the best of your knowledge.
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