ADHA COVID-19 PATIENT SCREENING QUESTIONNAIRE *Indicate Yes or No and provide relevant comments. Guidelines: To prevent the spread of COVID-19 and to reduce the potential risk of exposure to the workforce, please conduct this questionnaire, daily, at designated entry points, prior to accessing the site. Have you had close contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE? o Conduct the screening in a format that makes sense for your establishment. COVID-19 Screening Questions Symptom and exposure screening questions (check all that apply) Do you have a new onset, or worsening, of any ONE of the following symptoms? No Yes If YES, 1. o The questionnaire may be administered in various formats (e.g., in-person, over the COVID-19 Screening Tool reopeningri.com | health.ri.gov/covid REOPENING RI Recommended tool to screen employees, clients, and/or visitors for symptoms of COVID-19. visitors for onsite meetings should provide this questionnaire to each individual visitor sufficiently in advance so as to minimize inconveniences (travel, expenses, etc.). COVID-19 Risk Assessment Tool As you use this risk assessment tool, including the simple questionnaire at the end, the following four words should guide you: People, Space, Time, and Place. Yes No . Yes No • fever > 38°C or think you have a fever or chills • cough • sore throat/ hoarse voice • shortness of breath/ breathing difficulties • loss of taste or smell By signing below, I acknowledge that I have filled out this form voluntarily and have a full understanding of the information contained therein. Do you have a cough? Have you or has anyone in your house been tested for COVID-19 coronavirus in the past 14 days? Patient Name: Date: Do you have a fever, or have you felt feverish recently? Ontario Regulation 364/20. Version 6 . Screening Questionnaire and conduct symptom monitoring every day before entering CCAC buildings and facilities. 2.) Transmission of COVID-19 COVID-19 is easily spread in respiratory droplets by coughing or sneezing. COVID-19 HEALTH SCREENING TOOL. This health screening applies to all trades, suppliers, union reps, employees, etc. Coming to a CCAC campus or facility sick or with symptoms puts the entire college community at an unnecessary risk for spreading the novel coronavirus, the virus that causes COVID–19. The following questions are used to screen for COVID-19 before entry into a workplace (business or organization) as per Ontario Regulation 364/20. o It can be a questionnaire, with specific questions to help identify if an individual is reporting possible symptoms of COVID-19 or recent exposure to COVID-19. REV: March 21, 2020 1 . By … An official publication of the State of Rhode Island Have you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 Visitor Health Screening Questionnaire (COVID-19) At U. S. Steel, safety is our primary core value. COVID … Yes No Yes No Fever or chills Runny/stuffy nose Newly experienced any of the following symptoms that cannot otherwise be 1..attributed to another condition? What were the results? COVID-19 SCREENING QUESTIONNAIRE Date Time Name Birth Year Gender male femaleother B. COVID-19 Screening Tool for Workplaces (Businesses and Organizations) Version 1 – September 25, 2020 . _____ 2. 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