A Pineywoods Home Services Employee COVID-19 Check-in

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Please fill out the form below for our state mandated daily COVID-19 screening. Texas Department of Health and Human Services is requiring all clients and attendants to conduct COVID-19 screening prior to each scheduled shift to monitor change in possible symptoms and exposure events.

Attendant Name *

Client Name

I certify the following: 1.) I do not have any COVID-19 symptoms, 2.) I am not COVID-19 positive, 3.) I have not come in contact with anyone that is COVID-19 positive within the last 24 hours. *

Yes

If you answer "No" above, please indicate which statement is true.

I have a COVID-19 Symptom: feverish; chills; cough, sore throat, shortness of breath, or difficulty breathing; NEW or OUT OF THE ORDINARY runny nose and congestion; fatigue or muscle or body aches; headache; new loss of taste or smell; nausea or vomiting; diarrhea.

I have tested positive or diagnosed been with COVID-19

I have been in contact in the last 14, outside of healthcare of the work environment, with someone who has a confirmed diagnosis of COVID-19, is under investigation for COVID-19, or is ill with a respiratory illness

By checking the box below, you are agreeing to sign this form electronically by inputting your initials in the following section. By signing this form, you are agreeing and stating that all information contained in this form is accurate and complete. *

I Agree

Required

Please enter your initials below to electronically sign this form. *

Submit

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This form was created inside of A Pineywoods Home Health and Home Services.