AK COVID-19 Screening Questionnaire

The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential
risk of exposure, we are asking all ANNIE KARES IN-HOME CARE SERVICES, LLC families to complete and submit this questionnaire prior to in-home services.

We will require all ANNIE KARES IN-HOME CARE SERVICES, LLC families to complete a new questionnaire at least once every month.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and our other employees.

Client Name *

First Name Last Name

Caretaker/Parent Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Are you or any family members in the home currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.) *

	Yes	No
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
Cough
Shortness of breath or difficulty breathing
Sore throat
Loss of taste or smell
Chills
Headaches or muscle aches
Nausea, diarrhea, vomiting

In the past 14 days, have you or any family member been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

Yes No

In the past 14 days, have you or any family member been in close proximity to anyone who has tested positive for COVID-19? *

Yes No

Have you or any family member been tested for COVID-19 and are waiting to receive test results? *

Yes No

Have you or any family member have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? *

Yes No

In the past 14 days, have you or any family member been on a commercial flight or traveled outside of the United States? *

Yes No

In the past 14 days, have you or any family member been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States? *

Yes No

Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19? If “yes”, please provide a brief explanation. *

Yes No

Explain

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Signature *

Clear

Today's Date *

Date