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Reason For Screening:
|
Reason:
|
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Any Covid Symptoms?
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COVID Symptoms:
|
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Signs/Symptoms:
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Travel:
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Travel:
|
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When:
|
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Where:
|
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Exposure (+) or ? (+):
|
Exposure:
|
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If known, who:
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Plan for TESTING:
|
Location of Testing:
|
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Additional Testing Information:
|
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Date tested:
|
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Follow-Up:
|
COVID Result:
• • •
|
|
|
Date test resulted:
|
|
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RTW Date:
|
|
|
Management Notified:
|
|
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Additional Information:
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