Employee Caregivers

(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

Name

Email Address