Employee COVID Screen - Seva Senior Home Care Services

Caregiver Self-Screen

Please conduct this self-screening questionnaire before reporting to work. As it is required and important for health and safety purposes.

If you answer "YES" to any questions (1-5), you must notify your supervisor (click the submit button) immediately for further instructions. Please don't come to work until cleared by your healthcare provider or a physician. Only click submit if you have answered "YES" to any question.

(1) Do you have a temperature greater than or equal to 100.3 degrees? (1) Do you have a temperature greater than or equal to 100.3 degrees? YES NO

(2) Have you experienced any of the symptoms: Cough, Runny nose, sore throat, fever, vomiting, shortness of breath, chills, fatigue, diarrhea? (2) Have you experienced any of the symptoms: Cough, Runny nose, sore throat, fever, vomiting, shortness of breath, chills, fatigue, diarrhea? YES NO

(3) Have you had closed contact within approximately 6 feet of Covid-19 patient for more than 10 minutes or cared, lived with, visited or shared a room with someone diagnosed with Covid-19 or that had all the symptoms of Covid-19? (3) Have you had closed contact within approximately 6 feet of Covid-19 patient for more than 10 minutes or cared, lived with, visited or shared a room with someone diagnosed with Covid-19 or that had all the symptoms of Covid-19? YES NO

(4) Have you been diagnosed with Covid-19 or any health care provider have told you that you might have or have Covid-19? (4) Have you been diagnosed with Covid-19 or any health care provider have told you that you might have or have Covid-19? YES NO

(5) Have you run out of the correct personal protective equipment (PPE) such as a mask, gloves required to perform your job functions? (5) Have you run out of the correct personal protective equipment (PPE) such as a mask, gloves required to perform your job functions? YES NO

Covid-19 Compliance Covid-19 Compliance I have complied with Seva Senior Home Care Service agency procedures and policies to prevent the spread of Covid-19

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