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COVID TASK FORCE
Covid-19 Task Force
Covid-19 Screening
Please fill out the information below
Date of Call
Time of Call
First Name
Last Name
Person Calling
*
Required
Cambrian Employee
Cambrian Client
Family Member
Other
Type
*
Required
Adult
Respite
LVN
CWC
Self Direct
City
Follow-Up Phone Number
Choose symptoms reported below:
*
Required
Temperature 100.4 or higher
Temperature under 100.4
Coughing
Congestion
Shortness of Breath
Headache
Chills
New loss of taste or smell
Fatigue
Body Aches
Stomach Upset
No Symptoms at this time
Have you been exposed to Covid-19?
*
Required
Yes
No
Maybe
Don't Know
How long have you been having symptoms?
What PPE are/were you wearing with your client(s)?
Gloves
Mask
Gown
Face Shield
None
Not Applicable
Are there cleaning supplies in the client's home?
*
Required
Yes
No
Not Applicable
The caregiver works for another agency/facility:
*
Required
No
Home Care Agency
Skilled Nursing Facility
Hospital
Assisted Living
Group Home
Private Care Giving
Not Applicable
I don't know
Are you scheduled for a C-19 test?
Covid-19 Test Date
Test Site Location
Have you received the COVID-19 Vaccination?
Yes Vaccine Series, Yes Booster
Yes Vaccine Series, No Booster
No Covid Vaccine
What was the date of your last Covid vaccine shot?
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