COVID-19

COVID-19

Completion of this form will help Life Changes staff determine the most appropriate facility in which you will be housed and will keep you, other residents and staff safe and healthy. Please ensure you are wearing all required Personal Protective Equipment until it has been determined if you have been exposed or are in danger of spreading COVID-19.
Name *

First Name Last Name
Date *

Month Day Year
Date
Are You Our? *

Resident Visitor
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
COVID-19 Screening Tool
Date of your most recent COVID-19 test? *

Month Day Year
Date
Results - if you do not know, check your email for your most recent results *

Positive Negative Unknown/Or Have Not Been Tested
STOP!

IF YOU ANSWERED "POSITVE" TO QUESTION ABOVE, ENSURE YOUR FACE COVERING IS IN PLACE AND IMMEDATELY NOTIFY LIFE CHANGES STAFF

FOR RESIDENTS A POSITIVE COVID-19 TEST WILL REQUIRE YOUR PLACEMENT AT AN ALTERNATE FACILITY UNTIL YOU TEST NEGATIVE.

FOR VISITORS/VOLUNTEERS A POSITIVE COVID-19 TESTS PRECLUDES YOU FROM VISITING A LIFE CHANGES FACILITY.

If you answered "Negative" please complete this form.
Please check all symptoms you have experienced in the past 48 hours *

Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea None
Within the past 14 days, have you been in close physical contact (6 feet or closer for cumulative total of 15 minutes) with: *

Anyone who is known to have laboratory-confirmed COVID-19? Anyone who has symptoms consistent with COVID-19? None
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are you worried that you may be sick with COVID-19? *

Yes No
Did you answer NO to ALL QUESTIONS? If so, access to all Life Changes facilities is approved
Did you answer YES to ANY QUESTIONS? If so, full access to Life Changes facilities is not approved. IMMEDIATELY ensure your face covering is in place and notify your Intake Staff or House Manager. You will be provided housing in a quarantine situation and medical services will be provided
Signature *

Clear
Witness Name *

First Name Last Name
Witness Signature *

Clear
After completion of this form, residents are to the Intake Packet Form
Should be Empty:

COVID-19

COVID-19 Screening Tool