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COVID-19 Screening
Date:
Name
Phone:
Are you a staff member, volunteer, vendor, other:
Staff Member
Volunteer
Vendor
Other
In the last 14 days have you been in close contact with someone who had COVID-19 symptoms or tested positive? (Close contact meaning being within 6 feet of someone for more than 10 minutes.)
Yes
No
In the past 14 days have you experienced ANY of the following symptoms: fever (100F/37.8C or greater, cough, shortness of breath, difficulty breathing, sore throat, fatigue, new loss of taste or smell, chills, congestion, runny nose, headache, muscle or body aches, nausea, vomiting or diarrhea?
Yes
No
In the last 14 days have you traveled internationally or had contact with someone who traveled internationally?
Yes
No
What is your current temperature? (If greater than 100F or 37.8C, Contact LaKeesha Sowell)
I hereby certify that the responses provided above are true and accurate to the best of my knowledge. (Yes/No)
Yes
No
Thank you for contacting us.
We will get back to you as soon as possible.
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Phone: +1 832-617-8280
Fax: 832-
213-4500
Email:info@serenityhospicesolutions.com
Where to find us:
340 N Sam Houston PKWY E, Suite A222
Houston TX 77060, UNITED STATES
"Providing the Help you need at the Times you need it Most!"
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