Staff Screening Questionnaire

Please complete and submit the form below. It is a 2 page questionnaire that can be completed in approximately one minute. All fields require a response.
Step 1 of 2
In response to concerns regarding COVID-19 and other infectious viruses, and in accordance with guidance issued by CMS and the CDC, our facility has implemented screening protocol of staff for signs and/or symptoms of infection.

  • · All staff shall be screened at the beginning of their shift for fever and signs/symptoms.

  • · The employee’s temperature shall be taken and recorded, along with the absence of shortness of breath, new or worsening change in cough, and sore throat.

  • · If the employee is ill, have them put on a facemask and self-isolate at home. Employee shall be fever free for 24 hours without the use of medications before returning to work.

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