COVID-19: Screening Checklist for Visitors and Employees

• Conducted on

  Date

• Prepared by

• Location
  Address

• This checklist is derived from https://www.ahcancal.org/facility_operations/disaster_planning/Documents/COVID19-Screening-Checklist-SNF-Visitors.pdf

• ALL individuals (employees, family, visitors, government officials) entering the building must be asked the following questions:

• Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry?

  Yes

  No

• Please ask them to do so

• Ask the individual if they have any of the following respiratory symptoms? (If YES to any, restrict them from entering the building)

  Select Fever Sore throat Cough New shortness of breath

  • Fever
  • Sore throat
  • Cough
  • New shortness of breath

• Restrict them from entering the building

• If NO to all, is the individual an employee of this institution?

  Employee

  Non-employee

• 3A. For employees, check temperature and document results (not required for visitors)

• Fever present?

  No

  Yes

• Restrict from entering the building

• 3B. For employees, ask if they have:

• Worked in facilities with recognized COVID-19 cases?

  No

  Yes

• If YES, ask if they worked with person with confirmed COVID-19?

  No

  Yes

• If YES, restrict them from entering the building

• 4. Allow entry to building and remind the individual to:

• Wash their hands or use ABHR throughout their time in the building.

• Not shake hands with, touch or hug individuals during their visit.

• Visitors that are permitted for compassionate care situations must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility.

• 4. Allow entry to building and remind the individual to:

• Wash their hands or use ABHR throughout their time in the building.

• Not shake hands with, touch or hug individuals during their visit.

• Visitors that are permitted for compassionate care situations must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility.

• 4. Allow entry to building and remind the individual to:

• Wash their hands or use ABHR throughout their time in the building.

• Not shake hands with, touch or hug individuals during their visit.

• Visitors that are permitted for compassionate care situations must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility.

Completion

• Comments

• Signature

  Sign