COVID-19 Screening for Shelter Entrants
Personal Information
Name:
Date:
Contact Number:
Screening Questions
1. Do you have any of the following symptoms? (Select all that apply)
Fever
Cough
Shortness of Breath
Sore Throat
None of the above
2. Have you been in close contact with a confirmed COVID-19 case in the last 14 days?
Yes
No
3. Have you traveled outside of the country/state in the last 14 days?
Yes
No
Staff Use Only
Screened by:
Admittance Decision:
Admitted
Not Admitted
Referred for Health Assessment