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COVID TASK FORCE
Covid-19 Task Force
New Client Covid-19 Screening
Please fill out the information below
Client First Name
Client Last Name
Date of Call
Time of Call
Fever
*
Required
Yes
No
Temperature
For How Long?
Facility admission in the last 14 days?
*
Required
Yes
No
Coughing
*
Required
Yes
No
NEW Shortness of Breath
*
Required
Yes
No
If yes, date of last Covid test
Test Results
Have you been exposed to Covid-19 that you are aware of?
*
Required
Yes
No
If yes, please explain
Have your family members been exposed to Covid-19
*
Required
Yes
No
If yes, please explain
Do you have another agency coming into your home at present?
*
Required
Yes
No
If yes, name of agency and service provided
Have you travelled outside of the country recently?
*
Required
Yes
No
If yes, please explain
Have you received the COVID-19 Vaccination?
*
Required
Yes
No
Choose an option
Choose an option
What was the date of your last dose?
Continue
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