Front Desk Form PreBID Meeting~4.docx
DOCX document 22 KB Posted
- Attached to
- DHS Condenser Water Lines CMHC Small Purchase
- Solicitation number
- 22-444DHS-MENTH-B-25979
- Issued by
- Illinois
About this file
This document is a Front Desk Screening Questionnaire for the Department of Mental Health (DMH) facilities. The questionnaire is used to screen employees for COVID-19 symptoms and potential exposures prior to entering the facility. It includes questions about fever, COVID-19 symptoms, recent travel, and close contact with COVID-19 positive individuals. Based on the responses, the screening form outlines the appropriate actions to be taken, such as sending the employee home if they have a fever or have tested positive for COVID-19 within the past 10 days. The form also requires the staff member's initials to verify the screening process and notification of the Center Director if the employee is sent home.
The document does not contain information about a state or local contract opportunity. It is an internal screening procedure for DMH facilities to manage COVID-19 risks among their workforce.
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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 .