Repticity Guest Screen

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Dear Employee:

This checklist is mandated by the Centers for Disease Control and Prevention (CDC) and must be completed each time you report to duty.

Please have your temperature taken and kindly answer the questions below, and return the completed form to the front desk personnel.

Facility Q/A

Date

Facility

Shift

Guest Screening Questions

Phone Number

First Name

Last Name

Physician

Employee

Vendor

Visitor

Reason for Visit (if applicable) - For the safety of our residents, if visiting a resident please type their name

Swipe to adjust temperature
Anyone with temperature greater than 100° F must exit the building.

1. Are you having any signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat?	Yes No
2. In the last 14 days, have you had any contact with someone with a confirmed diagnosis of COVID19, or under investigation for COVID-19, or are ill with respiratory illness?	Yes No
3. Have you traveled domestically (within the US), internationally (outside the US) or traveled on a cruise ship within the last 14 days?As of June 30th - if you visited AL, AR, AZ, CA, FL, GA, IA, LA, MI, NC, NV, SC, TN ,TX or UT please select 'Yes'.	Yes No
Additional Details:
4. Do you reside in a community where community-based spread of COVID-19 is currently occurring?	Yes No
Additional Details:
5. Do you work at another Skilled Nursing Facility?	Yes No
Additional Details:

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Facility Q/A

Guest Screening Questions

Swipe to adjust temperatureAnyone with temperature greater than 100° F must exit the building.

Swipe to adjust temperature
Anyone with temperature greater than 100° F must exit the building.