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Completed by therapist in person prior to client entry to facility.
Indicates required field
Who is checking in?
In the last 10 days, have you or anyone you have been in close contact with, not felt well: headaches, cough, flu like symptoms, or diagnosed with covid?
In the last 21 days have you tested positive for covid?
Yes and received a follow-up negative covid test results. - Allow entry.
Yes and did not receive a follow-up negative covid test result. - Deny entry.
If YES to any prior question, do not allow entry or provide reasoning for allowing entry.
All is well so far, continuing pre-entry screening.
Notes / Actions taken
Length of stay
30 - 45 minutes
60 - 75 minutes
90 - 105 minutes
7:30am - 2:00pm work
2:00pm - 9:30pm work
7:30am - 9:30pm work