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COVID-19 Staff/Visitor Screening Tool
Please complete and submit the following COVID-19 screening tool each day.
Identification
This screening is being completed for a:
Staff Member
Visitor
First Name
Last Name
Phone Number
Estimated Duration of Visit
Room
Large Playroom
School Playroom
Small Playroom
EarlyON Playroom
Office
Kitchen
Caretaker Room
Observation Room
Back Hallway
Screening Questions
1. In the last [5, 10] days have you experienced any of these symptoms?
Fever and/or chills
Cough or barking cough (croup)
Shortness of breath
Decrease or loss of taste or smell
2. In the last [5, 10] days have you experienced any of these symptoms?
Sore throat or difficulty swallowing
Runny or stuffy/congested nose
Headache
Extreme tiredness
Muscle aches or joint pain
Nausea, vomiting and/or diarrhea
3. In the last [5, 10] days have you tested positive for COVID-19?
Yes
No
4. Do any of the following apply?
Yes
No
5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
Yes
No
6. Do any of the following apply?
Yes
No
Submit