15B40620QV9J40002_COVID-19 Screening Tool.pdf
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- Attached to
- Kitchen Ansul Suppression System Installation
- Solicitation number
- 15B40620QV9J40002
- Issued by
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Department of Justice Bureau of Prisons
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VISITOR/VOLUNTEER/CONTRACTOR COVID-19 SCREENING TOOL
3/13/20, Version 1.0
1. Have you…….
Yes No
a. Traveled from or through, any of the following locations identified by the CDC as increasing epidemiologic risk for COVID-19 within the last 14 days?
China, Iran, South Korea, Italy, Japan
Yes No b. Had close contact with anyone diagnosed with the COVID-19 illness within the last 14 days?
2. Do you currently have a …………
Yes No a. Fever or Chills
Yes No b. Cough
Yes No c. Shortness of Breath
3. Perform a temperature check ______◦F Method: oral / forehead (temporal) / tympanic
*Staff see instruction sheet for screening form.
Purpose of Visit (Circle one):
Attorney-legal / Contractor / Volunteer Social (visiting an inmate) – Inmate name/reg. number ______________________________ Other - ______________________________________________________________________
Visitor Name (Last, First): _____________________________________________________
Date: ______________________________________________________________________
Institution: _________________________________________________________________
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