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
Guest Screening Questions


Physician

Employee

Vendor

Visitor

 

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'.

(Swipe with your finger to sign above)