Staff Member Screening (Covid Screening)

* Required Information

Agency Name: Ascend Home Care

Staff Member Screened (Name) *

Job Title

Attendant	Home Health Aide
Contractor	Employee/Supervisor
Volunteer	Physical Therapist
Occupational Therapist	Speech Therapist
Registered Nurse	Licensed Vocational Nurse

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

Are you experiencing any of these symptoms?

Yes

No

Please select the symptoms

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.

Staff Signature *

Date

Time