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Form – COVID Questionnaire
Matt Auman
2020-08-10T15:34:45-04:00
New Employee COVID Assessment
Introduction - COVID Screening Questionnaire
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Before beginning or returning to work at HomeCentris Healthcare and its subsidiaries, the company will screen each prospective or returning employee using the following questions. Any positive indications (“Yes” answers) will be immediately forwarded to the Clinical Services Manager for evaluation prior to start of work. Thank you for your time.
Employee Name
Have you traveled internationally within the last 14 days?
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Yes
No
If "yes", please type the country or countries visited.
Have you traveled outside the state of Maryland in the last 14 days?
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Yes
No
If "yes", please type the state(s) visited.
Do you currently have any signs or symptoms of a respiratory infection, such as a fever, cough, diarrhea, stuffy or runny nose, or sore throat?
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Yes
No
If "yes", were you given a diagnosis by your doctor?
Yes
No
If “Yes”, what diagnosis were you given?
In the last 14 days, have you had contact with someone with or under investigation for COVID-19, which is often referred to as the Corona Virus?
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Yes
No
In the last 14 days, had you had contact with someone who is ill with a respiratory illness?
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Yes
No
Signature
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Date
If you are human, leave this field blank.
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