ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAE
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Note: Tab 2 has instructions
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SCREENING LOG
DATE: ________________
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NOTE: Screening questions first, temperature last
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TIMENAME (first and last)Destination
Exposure
Cough
Shortness of breathLoss smell/ tasteMuscle PainChillsHeadacheSore ThroatANY SYMPTOMS in the last 48 hrsLast Dose Acetaminophen (Tylenol) or Ibuprofen (Advil)TEMP <100.0ACCEPTInitials
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00:00I M ScreenerNoNoNoNoNoNoNoNoirritated eyes (pollen)5/1298.2YesIMS
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00:05Ben TeacherNoNoNoNoNoNoYesNoheadache7 am98.6NOIMS
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Screener Name (print): Screener Name (print): Screener Name (print):
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