* Required Information

Agency Name: Ascend Home Care

The COVID 19 symptoms listed on the CDC website are:

  • Fever (as measured with a thermometer)
  • 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

I confirm that for each signature below, I conducted a self-screening for conditions, signs, and symptoms of COVID-19 prior to providing service to agency clients at the times and dates noted and signed, unless I met a condition, sign, or symptom of COVID-19, in which case I notated such and complied with agency policy including notifying appropriate agency personnel.