COVID Screening Questionnaire

COVID Screening Questionnaire

With the emerging Coronavirus (COVID-19) concerns, we strive to provide the safest environment for our community. All visitors should complete the Coronavirus (COVID-19) Exposure Questionnaire before entering the facility. Individuals with any of the conditions described in the questionnaire should be restricted from entering the program.
Name *

First Name Last Name
Today's Date

Month Day Year
Date
I am a: *

Employee Parent of a Student Visitor Contractor
Name of Department or Company:
If You are a Parent, Name of Student:

First Name Last Name
Reason for Visit:
Have you or a close contact (household member) traveled outside of Massachusetts in the last 14 days: *

Yes No
If Yes, where did you travel? *
Have you had close contact with a person diagnosed with Coronavirus/Covid-19, under investigation for Covid-19, or ill with a respiratory illness? *

Yes No
Do you have any of the following symptoms? (Check all that apply): *

Sore Throat Cough Fever (over 100.4) Dizziness Shortness of Breath Loss of Taste or Smell New Muscle Joint Pain Vomiting or Diarrhea Abdominal Pain No Symptoms
Have you been in close contact, meaning living in the same home and/or being in the same confined space (less than 6 feet apart), with someone who has/had any other the following symptoms: *

Sore Throat Cough Fever (over 100.4) Dizziness Shortness of Breath Loss of Taste or Smell New Muscle Joint Pain Vomiting or Diarrhea Abdominal Pain No Symptoms
*If ANY of the symptom boxes above are checked, you should NOT enter the facility.*

If NONE of the symptom boxes above are checked, please proceed to have your temperature taken.

*If your temperature is currently 100.4 or higher, you should NOT enter the facility.*

If your temperature is under 100.4 degrees, please wash/sanitize your hands and enter the facility.
MASKS ARE REQUESTED TO BE WORN AT ALL TIMES
As viruses can be spread to other people, please take the following steps to keep yourself and others healthy:
- Wash your hands often with soap and water for at least 20 seconds
- Use an alcohol-based hand sanitizer with at least 60% alcohol
- Avoid touching your eyes, nose, and mouth
- Sneeze or cough into your sleeve or preferably a tissue, then throw the tissue into the trash and wash your hands
- Stay home when you are sick
- Avoid close contact with people who are sick
- Frequently disinfect cell phones and other frequently touched objects and household surfaces such as light switches, doorknobs, countertops and toilets
Please contact the Director of Nursing, Lynn Power, or the Human Resources Manager, Cristin Tagman, if you are unable to proceed into the facility.

Thank you for your assistance in keeping our community safe.
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