Health Screen for In-Person Home Visiting

Form must be returned to your service provider at least 2 hours prior to scheduled session, or session will need to be rescheduled.

Screens should be completed for all persons and participant/family members who will be present during the visit.

For the safety of all individuals, please respond accurately to all questions.

Name of person completing form

First Name

Last Name

Child's Name

First Name

Last Name

Date and time of scheduled visit

1. Has any member of your household tested positive for COVID-19 in the past 5 days, OR is any member of your household waiting on COVID-19 test results?

Yes

No

2. Does any member of your household have signs of illness, including fever, chills, nausea/vomiting, congestion, cough, or shortness of breath?

Yes

No

3. Does any member of your household currently have an infectious disease, including but not limited to: the flu, pink eye, RSV, strep throat, hand foot and mouth disease, or pneumonia?

Yes

No

If you have answered yes to the questions above, in-person visiting is not recommended at this time. Please contact your provider to reschedule.

Thank you for your cooperation and understanding!