YES . Hit the button Use this template below to start editing your online form. Topics covered include medical questionnaires and taking an employee's temperature in the workplace, disclosure of an employee's exposure to COVID-19, reasonable accommodations, the interactive process, and confidentiality concerns. 1. Help us prevent spread Read this carefully. The questionnaire simply asks if your client has experienced symptoms of COVID-19 or has come into contact with someone experiencing symptoms. Available in A4 & US Sizes. Do you currently have symptoms of a respiratory infection? COVID-19 Screening Questions for Clients and Community Members . NO b. In addition to informing care decisions, the information collected from a well-designed pre-visit screening questionnaire can be part of an effort to reduce community spread of COVID-19. SFDPH discourages anyone from denying core essential services (such as food, medicine, shelter, or social services) to Employee COVID-19 Self Screening Questionnaire tracks the health condition of your employee and helps to take the precautionary measures to prevent the spreading of coronavirus in the workspace. Do you have any of the following symptoms? I have not knowingly been in contact with anyone diagnosed with Covid-19 in the past 2 weeks. a. 1. The EEOC selected 22 questions to answer from over 500 questions submitted to the agency related to COVID-19. COVID-19 SCREENING QUESTIONNAIRE We take the responsibility of keeping our employees and customers safe very seriously. ____ 4. If you choose to add any legal language, please consult with your attorney. Provide Information: Question 2: Have you returned from travel (including travel within Canada) in the last 14 days OR had *exposure to a confirmed positive case of COVID-19? ____ 3. Question 1: Do you have any cold or flu-like symptoms? Current Temperature _____°F. ATTACHMENT A-2: San Francisco COVID-19 Health Screening Form for Non-Personnel (November 2, 2020) This handout is for screening clients, visitors and other non-personnel before letting them enter a location or business. Fully customizable with no coding. Templates — COVID-19 Medical Questionnaire Template We created this form template to help various public and private institutions survey their audiences and capture the symptoms of COVID-19 disease. COVID-19 screening questions Download the alternative format (PDF format, 518 KB, 1 page) Organization: Correctional Service Canada. Easily Editable & Printable. COVID. YES. CSC is currently taking measures to ensure your safety, the safety of our staff and offenders and limit the risk of infection. Initial . Screening Questionnaire – COVID-19 (Coronavirus) Questions asked at initial screening: Name:_____ Date:_____ Please circle the appropriate responses. A coronavirus COVID-19document includes all sorts of paper and document businesses and companies use during the pandemic to address people. It can be a letter, memo, survey, and others. Covid-19 Client Intake Questionnaire . Covid-19 Questionnaire/Release Dear valued client's, We want you to know that your health as well as your families health and safety remains our first priority here at … Instantly Download Free COVID-19 Checklist Templates, Samples & Examples in Microsoft Word (DOC), Google Docs and Google Sheets (SPREADSHEETS) Format. Quickly Customize. We are asking our employees and guests to provide information regarding any symptoms of, or exposure to COVID-19, with this simple screening questionnaire. My temperature has not been above 98.6°F in the past 72 hrs. 2. If you look into the coronavirus map, you can see that almost all the countries around the globe have been affected by … It also asks that your client contact you if he or she does notice symptoms up to two weeks after their appointment. Beauty Salon COVID 19 Liability Waiver Date published: 2020-04-01.