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Health Screener - Visitor

The Center of Disease Control (CDC) and Centers of Medicare and Medicaid Services (CMS) have issued guidance for long term care facilities. In accordance with this guidance, we are screening and monitoring all visitors at this time.
We value the safety and welfare of the residents we care for and appreciate your understanding the need for all visitors to complete this required form, related to the potential need to restrict visitors who may pose any risk to our residents.
It is your right to not complete the screen. If you choose to not be screened, you will be restricted from visitation at the facility until further notice.

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Enter Visitor First Name

Enter Visitor Last Name

Phone Number

Are you visiting one or more residents today?

Question	Answer
Visitation Date
Have you traveled outside your state of residency by any means other than personal vehicle in the last 14 days?
Take and record temperature
Have you taken any medication in the last 4-6 hours related to a new onset of flu or cold like symptoms that contain fever reducing medications such as: Tylenol, Ibuprofen, aspirin, naproxen or cold medication.
Have you been in direct contact with anyone who active COVID-19 in the last 14-days.
Have you tested positive for COVID-19 in the last 10 Days?
Are you currently pending results of a COVID-19 Test from a source other than this community?
Have you experienced any of the following symptoms in the past 48 hours: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?

By clicking the submit button below, you acknowledge that you have answered the questions truthfully and to the best of your ability. You also acknowledge the harm that can come to the residents and staff by falsifying your answers and withholding important information such as testing COVID-19 positive or pending test results.