COVID-19 SCREENING TOOL Use this tool to screen Employees, Clients and/or Visitors for symptoms of COVID-19. Personal InfoTodays Date *First Name *Last Name Email *Phone * Symptoms HAVE YOU HAD ANY OF THE FOLLOWING SYMPTOMS IN THE PAST THREE DAYS THAT ARE NOT EXPLAINED BY ALLERGIES OR A NON-INFECTIOUS CAUSE?COUGH *YESNOSHORTNESS OF BREATH OR DIFFICULTY BREATHING *YESNOFEVER OR CHILLS *YESNOMUSCLE OR BODY ACHES *YESNOSORE THROAT *YESNOHEADACHE *YESNONAUSEA OR VOMITING *YESNODIARRHEA *YESNORUNNY NOSE OR STUFFY NOSE *YESNOFATIGUE *YESNORECENT LOSS OF TASTE OR SMELL *YESNO Risk FactorsHave you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days? *Does not apply to people who come into contact with people with symptoms of COVID-19 during the course of their daily work while wearing full and appropriate personal protective equipment (PPE). See https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html for more information.YesNoHave you traveled anywhere outside the 50 United States in the past 14 days? *YesNoHave you traveled to Rhode Island for a non-work-related purpose from a location with a high community spread rate? *see list maintained by the Rhode Island Department of Health (RIDOH) at www.health.ri.gov/covid Public health, public safety, and healthcare workers are exempt. Does not apply to anyone traveling for medical treatment, to attend funeral or memorial services, to obtain necessities like groceries, gas, or medication, to drop off or pick up children from day care, summer camps, or to anyone who must work on their boats. Does not apply to people who have had a negative COVID-19 test from a specimen taken no more than 72 hours prior to arrival in Rhode IslandYesNoHave you been directed to quarantine or isolate by the Rhode Island Department of Health or a healthcare provider *YesNoIf so, when does your Quarantine or Isolation period end? If you have answered "Yes" to any of the questions above, you will be asked to leave the building. *Employees : Please Contact Your Supervisor and Your Human Resources Representative. *Visitors : Please Call To Discuss When You Can Return To This Facility. VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
