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Mandatory COVID-19 Screening
Please fill out this quick survey prior to your visit to help everyone stay safe and healthy!
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* Indicates required question
Your name:
*
Your answer
2. Do you have any of the following signs or symptoms?
*
New onset of cough
Worsening chronic cough
Sore throat
Shortness of breath
Difficulty breathing
New loss or decrease in sense of taste or smell
Runny nose
Sneezing (not allergy related)
Hoarse voice
Nasal congestion
Chills
Headache
Unexplained fatigue or malaise
Difficulty swallowing
Nausea/vomiting, diarrhea, abdominal pain
No
Other:
Required
3. Have you travelled or have had close contact with anyone who has travelled in the past 14 days? *
*
Yes
No
4. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19? *
*
Yes (if yes, go to question 5)
No (if no, screening is complete)
5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures when you had close contact with a suspected or confirmed case of COVID-19?
Yes
No
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If you have answered "yes" to questions 1, 3, or have checked off signs or symptoms, you may need to reschedule your appointment. If you have answered "yes" to question 4 but "yes" to question 5, you may proceed with your appointment.
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