COVID-19 Checklist for Individuals and Families (CDC)

• Conducted on

  Date

• Prepared by

• Location
  Address

• This checklist is derived from the Checklist for Individuals and Families by the Centers for Disease Control and Prevention (CDC).
  https://www.cdc.gov/coronavirus/2019-ncov/community/home/checklist-household-ready.html

Plan and Prepare

• Get up-to-date information about local COVID-19 activity from public health officials

  Yes

  No

• Create a household plan of action

• Consider members of the household that may be at greater risk such as older adults and people with severe chronic illnesses.

  Yes

  No

• Ask your neighbors what their plan includes.

  Yes

  No

• Create a list of local organizations you and your household can contact in case you need access to information, healthcare services, support, and resources.

  Yes

  No

• Create an emergency contact list including family, friends, neighbors, carpool drivers, healthcare providers, teachers, employers, the local public health department, and other community resources.

  Yes

  No

• Choose a room in your house that can be used to separate sick household members from others.

  Yes

  No

• Take everyday preventive actions

• Wash your hands frequently

  Yes

  No

• Avoid touching your eyes, nose, and mouth.

  Yes

  No

• Stay home when you are sick.

  Yes

  No

• Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

  Yes

  No

• Clean and disinfect frequently touched objects and surfaces Be prepared if your child’s school or childcare facility is temporarily dismissed or for potential changes at your workplace.

  Yes

  No

Take Action

• In case of an outbreak in your community, protect yourself and others

• If you develop emergency warning signs for COVID-19 get medical attention immediately. In adults, emergency warning signs*:<br>• Difficulty breathing or shortness of breath<br>• Persistent pain or pressure in the chest<br>• New confusion or inability to arouse<br>• Bluish lips or face<br>*This list is not all inclusive. Please consult your medical provider for any other symptom that is severe or concerning.

  Yes

  No

• Keep away from others who are sick

  Yes

  No

• Limit close contact with others as much as possible (about 6 feet)

  Yes

  No

• Put your household plan into action

• Continue to practice everyday preventive actions

  Yes

  No

• If someone in the household is sick, separate them into the prepared room

  Yes

  No

• If caring for a household member, follow recommended precautions and monitor your own health

  Yes

  No

• Keep surfaces disinfected

  Yes

  No

• Avoid sharing personal items

  Yes

  No

• If you become sick, stay in contact with others by phone or email

  Yes

  No

• Stay informed about the local outbreak situation

  Yes

  No

• Notify your work if your schedule needs to change

  Yes

  No

• Take care of the emotional health of your household members, including yourself

  Yes

  No

• Take additional precautions for those at highest risk, particularly older adults and those who have severe underlying health conditions.

• Consider staying at home and away from crowds if you or a family member are an older adult or have underlying health issues

  Yes

  No

• Make sure you have access to several weeks of medications and supplies in case you need to stay home

  Yes

  No

• When you go out in public, keep away from others who are sick and limit close contact with others

  Yes

  No

• Practice good hand hygiene

  Yes

  No

• Take the following steps to help protect your children during an outbreak

• Notify your child’s school if your child becomes sick with COVID-19

  Yes

  No

• Keep track of school dismissals in your community

  Yes

  No

• Discourage children and teens from gathering in other public places

  Yes

  No

Sign-off

• Comments/Recommendations

• Name & Signature

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