Client Screening Responses

***COMPLETE THIS ONLY IF CLIENT HAS ONE OR MORE "YES" ANSWERS TO THE QUESTIONS.***

This form is only to be used by admin employees to enter data.

Select or enter value
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Resides in 24 hour site:*
1. Has the client received the COVID-19 Vaccine?*
If yes, what is the Vaccination Type?

2. Within the last 14 days, has the client experienced a NEW fever or chills, shortness of breath or difficulty breathing, cough, muscle or body aches, fatigue, sore throat, new loss of taste or smell, diarrhea, nausea/vomiting, congestion/runny nose, headache?*

3. Within the last 14 days, has the client or someone they live with been exposed to an individual with a positive COVID-19 diagnosis?*

If exposed - is the client quarantined?
4. If exposed by an employee, was the employee wearing PPE?

Select from the dropdown below

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Was Client wearing a mask?
5. Within the last 14 days, has the client tested positive for COVID-19?*

Is client receiving services?*

(If positive client will continue to receive service, make sure appropriate PPE kits are ordered and employees receive hero pay.)

Are client services on hold?*

(If positive, client will continue to receive service, make sure appropriate PPE kits are ordered and employees receive hero pay.)

If yes, this is due to:

Please list all employees who came in direct contact

Please list all employees who came in direct contact (within 6ft for a total of 15min in 24 hours) from the period 48 hours before symptom onset to the time at which the client was isolated:

Is this person a preferred caregiver?
Was Employee wearing PPE?

(if more than one employee was exposed)

(if more than one employee was exposed)

Is this person a preferred caregiver?
Was Employee wearing PPE?

(if more than one employee was exposed)

(if more than one employee was exposed)

Is this person a preferred caregiver?
Was Employee wearing PPE?

If more than 3 employees, please include the additional name(s), exposure date(s) and if wearing PPE in Employee Exposed box above.

Are these employees quarantined?

***Please submit the Employee Response Form for each employee listed above who has been exposed to a COVID-19 positive client.

Please list all clients exposed within the same household

Did you notify the Health Department?
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