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 Have you or has anyone in your house been tested for COVID-19 coronavirus in the past 14 days? 2.) visitors for onsite meetings should provide this questionnaire to each individual visitor sufficiently in advance so as to minimize inconveniences (travel, expenses, etc.). is being investigated or confirmed to be positive for COVID-19? ADHA COVID-19 PATIENT SCREENING QUESTIONNAIRE *Indicate Yes or No and provide relevant comments. This tool provides basic information only and contains recommendations for businesses or organizations for COVID-19 screening as per . Do you have chills or repeated shaking with chills? What the date of your test? No Yes If YES, 1. 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. To reduce the risk of spread of COVID-19 in the workplace, employees should be screened prior to entering work. COVID-19 SCREENING QUESTIONNAIRE Date Time Name Birth Year Gender male femaleother B. 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. Screening Questionnaire and conduct symptom monitoring every day before entering CCAC buildings and facilities. COVID … This health screening applies to all trades, suppliers, union reps, employees, etc. COVID-19 HEALTH SCREENING TOOL. Employees can self-screen in advance of work and on site. Ontario Regulation 364/20. 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? _____ 2. Patient Name: Date: Do you have a fever, or have you felt feverish recently? Yes No Yes No Fever or chills Runny/stuffy nose Version 6 . 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 Have you had close contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE? It is not to be used 1. 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. 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. I also agree that all the information provided is accurate to the best of my knowledge. _____ The following questions are used to screen for COVID-19 before entry into a workplace (business or organization) as per Ontario Regulation 364/20. They can also be used for other activities. Do you have a cough? By … As the outbreak of the coronavirus disease 2019 (COVID-19) o Conduct the screening in a format that makes sense for your establishment. REV: March 21, 2020 1 . Yes No . Visitor Health Screening Questionnaire (COVID-19) At U. S. Steel, safety is our primary core value. COVID-19 Screening Questionnaire 1. Transmission of COVID-19 COVID-19 is easily spread in respiratory droplets by coughing or sneezing. COVID-19 Screening Tool for Workplaces (Businesses and Organizations) Version 1 – September 25, 2020 . o The questionnaire may be administered in various formats (e.g., in-person, over the Are you having shortness of breath or any difficulty breathing? What were the results? Newly experienced any of the following symptoms that cannot otherwise be 1..attributed to another condition? By signing below, I acknowledge that I have filled out this form voluntarily and have a full understanding of the information contained therein. 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