COVID 19 Daily Form

COMMUNITY ILLNESS
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The vast majority of the illnesses around the world are mild, with fever and cough. This screening tool is to help communities identify immediate potential risk. Screening is done over the phone, or in a manner where the screener maintains the recommended social distance of 6 feet, if practical. Persons who answer "yes" to the following questions should not visit and/or be evaluated further.
Have you traveled in the last 14 days to an area of high risk, such as China, South Korea, Hong Kong, Japan, Italy, or Iran, or a local area of high risk with confirmed infected individuals?

Yes No
Have you been in close contact with someone who has traveled to an area of high risk in the last 30 days, and are having symptoms of an illness?

Yes No
Do you have or have you recently had a fever or elevated temperature?

Yes No
Do you have a cough, shortness of breath, or other lower respiratory symptoms, such as chest tightness and wheezing upon exhaling, that is new and not part of a chronic health condition, such as emphysema or COPD?

Yes No
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Should be Empty: