The Perfect Playground Clinic - COVID Screening
Email Address of (Parent/Guardian/Staff/Visitor)
Email address *
First and Last Name (of person entering clinic for therapy or to work) *
Within 24 hours of student’s scheduled therapy session in the clinic, the family will need to respond to the following questionnaire:
Has anyone in the household had a fever of 100.4 or higher, cough, shortness of breath, difficulty breathing, chills, muscle pain, sore throat, new loss of taste or smell, etc? *
Has anyone in the household tested positive for COVID-19 in the past 14 days (diagnostic test, not a blood test for antibodies)? *
Has anyone in the household been in close contact (for 10 minutes within 6 feet or any direct physical contact) with a person with COVID-19 symptoms (fever, cough, shortness of breath) or a confirmed COVID-19 infection within 14 days? *
Has anyone in the household been told by their health care provider or the NYC Test & Trace Corps to remain home due to being exposed to COVID-19? *
Has anyone in the household been required to quarantine based on the New York State COVID-19 Travel Advisory?( *
If any of the above statements are YES, in person services would not be allowed to occur. During the 14 day quarantine period, the therapist would work with the family to schedule therapy sessions to occur remotely. *
If a session is cancelled due to concerns about COVID-19, the parent/guardian will need to provide the office with a doctor’s note or negative COVID test before the student is allowed to resume in person services. *
It is important to be able to seamlessly shift back to providing services remotely. In the event that the service can no longer be delivered in person, follow the guidance on remote service provision. *
A copy of your responses will be emailed to the address you provided.
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