Therapeutic Links COVID-19 Face to Face Daily Assessment
If you answer YES to any below questions, then services may not be conducted, effective immediately. OT services will be reinstated per guidelines of the CDC and IL mandate.
Client's Name *
Client's Date of Birth *
Date and Time of Session. DO NOT FILL THIS FORM OUT MORE THAN 12 HOURS BEFORE SESSION. *
Does any member of the household have a confirmed case of COVID-19? *
Has any member of the household come into contact with a confirmed case of COVID-19 in the past 14 days? *
Has any member of the household shown signs of COVID-19, as outlined by the CDC, such as cough, shortness of breath, runny nose, sneezing, respiratory illness, within the last 7 days? *
Has any member of the household had a fever of 100.4 or higher in the last 7 days? *
Has any member of the immediate family traveled internationally within the last 7 days? *
Has any able member of the family NOT abided by IL recommendation of wearing face masks in public and/or practicing social distancing? *
By electronically signing this form (Typing your name below), I acknowledge that the answers I provided are correct and therefore valid. *
Next
Never submit passwords through Google Forms.
This form was created inside of therapeuticlinks.com. Report Abuse