Front Desk Form PreBID Meeting~3.docx
DOCX document 22 KB Posted
- Attached to
- DHS Replacement Sink CMHC Small Purchase
- Solicitation number
- 22-444DHS-MENTH-B-25819
- Issued by
- Illinois
About this file
This document is a Front Desk Screening Questionnaire for the Department of Mental Health (DMH) facilities. It outlines the protocol for screening employees for COVID-19 symptoms and potential exposures prior to starting their shifts. The questionnaire covers topics such as fever, COVID-19 symptoms, recent travel, and close contact with confirmed or suspected COVID-19 cases. Based on the employee's responses, the screener is instructed to take appropriate actions, such as sending the employee home if they have a fever or tested positive for COVID-19 within the past 10 days. The document also requires the screener to notify the Center Director if an employee is sent home.
The document does not provide any information about a state or local contract opportunity. It is focused solely on COVID-19 screening procedures for DMH facility employees.
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Text version
DMH FRONT DESK SCREENING QUESTIONNAIRE
Revised 8-26-21 Facility Name:_______________________
| Name of Employee/Title |
| Date/Shift |
| Temp |
(if fever present >100.0F, staff immediately sent home).
Document temperature below:
If sent home due to elevated temp – indicate “sent home” next to temperature Initial of staff verifying they asked if the employee had any of the following symptoms in the last 48 hours:
· Fever or chills
· Cough
· Shortness of breath or difficulty breathing
· Fatigue
· Muscle or body aches
· Headache
· New loss of taste or smell
· Sore throat
· Congestion or runny nose
· Nausea or vomiting
· Diarrhea
Have you traveled on a cruise ship or internationally within the last 14 days
Yes OR No
Yes – if not fully vaccinated employee is sent home for 7 days if tested within 3-5 days after arrival and negative, for 10 days if not tested, tested positive or does not wish to share vaccine status
OR
If fully vaccinated test within 3-5 days and may work if not symptomatic Have you been in prolonged, close contact (< 6 feet for > 15 minutes) to a patient,visitor or healthcare worker with confirmed COVID-19 while not wearing recommended PPE or to a person in the community suspected of having or has tested positive for COVID 19 within the last 14 days?
YES- (if not fully vaccinated, test through primary care physician, employee is sent home unless employee has recovered from SARS-CoV-2 infection in the last 90 days)
OR
YES- (if fully vaccinated, test immediately and every 3-7 days, if fully vaccinated or have recovered from COVID 19 within the past 90 days: monitor symptoms, employee can continue to work using a mask as long as they test negative and have no symptoms.)
Have you tested positive for COVID-19 within the past 10 days (asymptomatic or symptomatic)?
Yes or No (yes employee is sent home)
| Employee asked checklist questions – action taken as needed for any “yes” answers – staff initials verifying action taken |
| Verify date/time Center Director is notified. |
(Center Director is notified if employee sent home/ if employee is not send home put N/A in the box)
File details come from the government source that posted it. Updated .