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COVID Screening
SSHA COVID-19 Staff Screening Form for Homelessness Service Settings. All staff must complete this form daily prior to attending their location of work.
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* Indicates required question
Date of Shift
*
MM
/
DD
/
YYYY
Name
*
Your answer
Time of Shift
*
7:00 am
7:30 am
8:00 am
3:00 pm
3:30 pm
4:00 pm
11:00 pm
11:30 pm
12:00 am
Other:
Required
Location of Shift
*
Hotel
Drop-In
Transitional Housing
Community Living
Other:
Required
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