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CDPAP
Home Care Services
Home Health Aides
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Veterans Home Care
Resources & Information
FAQs
Resources
COVID-19
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About
Screening Form
Coordinator Name
(Required)
Coordinator Email
(Required)
Caregiver Name
(Required)
Caregiver Code
(Required)
Required Start Date
(Required)
Has caregiver had contact with any Persons under Investigation (PUIs) for COVID-19 within the last 10 days, or with anyone with known COVID-19?”
(Required)
No
If Yes, Please explain
If Yes, Please explain
Have you been diagnosed/tested positive/treated/suspected for COVID-19 by a licensed health professional or placed under voluntary or mandatory quarantine in the past 10 days?
(Required)
No
Yes, If tested positive, please provide a date
If YES, date of the test :
MM slash DD slash YYYY
Do you currently have or had in the past 48 hours fever, cough, shortness of breath, sore throat, loss of taste/smell?
(Required)
No
If Yes, Please explain
If Yes, Please explain
If you answered YES to any questions, please report to DPS
