Tampa General Hospital COVID-19 Screening Questionnaire
Tampa General Hospital developed a screening tool to use for patients and healthcare workers suspected of COVID-19 infection. Patients can be screened via phone or in person. The form includes these questions:
• Have you returned from a visit to China, Japan, Iran, South Korea, or Italy?
• Have you been in contact with a person who has returned from one or more of the above countries in the past 14 days who also exhibits respiratory symptoms (fever, cough, difficulty breathing)?
If you answered no to all the above questions, you do not need to continue. If you answered yes to any of the above questions, please complete all sections below:
Do you currently feel ill or have any respiratory symptoms or fever? If yes, please answer below.
Have you had any of the following during the past 14 days:
• Fever of 100°F or greater. If yes, when did the fever start?
• Do you have a cough? If yes, when did the cough start?
• Do you have difficulty breathing? If yes, when did this start?
• Do you have any other symptoms? If yes, describe.
• Describe countries and cities you or contact person visited with dates.
• Describe contact you had with person with COVID-19.
• Date you or contact person returned to U.S.
Team Member Health Section
• Temperature
• Blood pressure
• Pulse
• Respiration
• Team member/healthcare worker symptomatic. Referred to team member director/manager. Not cleared to work.
• Team member placed on administrative leave and advised to self-quarantine. Must return to TM Health clinic for clearance.
• Team member cleared to work per team member director.
• Called Florida Department of Health to determine if COVID-19 testing should be performed.
SOURCE
• JoAnn Shea, ARNP, MS, COHN-S, Director, Employee Health and Wellness, Tampa General Hospital
Tampa General Hospital developed a screening tool to use for patients and healthcare workers suspected of COVID-19 infection. Patients can be screened via phone or in person.
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