COVID-19 Screening

HFT BULLETIN BOARD

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COVID 19 SCREENING FOR CLINICIANS.

* Indicates required field

Name *

First

Last

Do you have a new cough? *

Yes No

Do you have a new shortness of breath? *

Yes No

Do you have a fever (100.4 or higher)? *

Yes No

DO YOU CURRENTLY HAVE ANY OF THESE SYMPTOMS?

CHECK ALL THAT APPLY *

fatigue congestion or runny nose sore throat headache new loss of taste or smell diarrhea muscle or body aches nausea or vomiting NONE OF THE ABOVE

Have you been in close contact (within 6 feet for more than 15 minutes) with someone who has received a laboratory tested diagnosis of COVID 19 in the past 14 days?

Close Contact *

Yes No

BY CLICKING SUBMIT I AM CERTIFYING THAT THE ABOVE INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.

Submit

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