CTD Daily Health Screening

You must answer “NO” to all the questions in this questionnaire in order to see your CTD Client. If you answer “YES” to any of the questions, please DO NOT go into the client's home, school or our sensory clinic.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify CTD OT admin staff AND your client.

Please read and follow the CDC’s guidelines for anyone who might have or has been exposed to COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html. Sessions will not take place if you answered yes to any of these questions.

NUMBERS TO REMEMBER
Office: 212 290-0290 (phone) // 833-748-0147 (remote fax)

Have you experienced a fever of 100.4 degrees F or greater, a new cough, or shortness of breath within the past 10 days?*

YesNo

In the past 10 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (not a blood test)*

YesNo

To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone while they had COVID-19 or symptoms of COVID-19 (fever, cough, or shortness of breath).*

YesNo

In the past 14 days, have you been told by a health care provider or the NYC Test & Trace Corps to remain home due to being exposed to COVID-19?*

YesNo

In the past 14 days, have you been required to quarantine based on the New York State COVID-19 Travel Advisory?*

YesNo

Signature*

Name*

First NameLast Name

Date*

Date