COVID-19 Self Screening Questionnaire

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location or any of our partner clinical facilities. If you answer “YES” to any of the questions, please DO NOT enter the company’s buildings. If you experience any symptoms or answer “YES” to any of these questions, you must get tested immediately and isolate until you receive your test results. If you test positive, follow isolation recommendations per CDC, contact your health care professional AND notify Alliance Specialty HCS.

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

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

	Yes	No
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 skills lab or clinical. You should: Self-quarantine for at least 5 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 or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come into skills lab or clinical. You should self quarantine for at least 5 days. I certify to the best of my knowledge; this information is accurate.

Signature*

Name*

First NameLast Name

Date*

Date

Employee COVID-19 Self Screening Questionnaire