COVID-19 SCREENING
- Have you had any of the following symptoms in the past week?
- Fever
- Cough
- Difficulty breathing
- Sinus congestion/ stuffy nose
- Sore throat
- Runny nose
- Shortness of breath
- Wheezing or chest tightness
- Sneezing
If NO SYMPTOMS -> STOP – no further action required. Patient may come into clinic
If Yes, they HAVE SYMPTOMS - > Move on to Question 2.
- Have you traveled to of from any of the countries listed below in the past 14 days and/or had close contact with a person who is under investigation for Covid-19?
- China
- South Korea
- Iran
- Italy
- Japan
If No to Question 2 - > STOP – No further action required. Patient may come into clinic under droplet precautions
If yes to Question 2, complete the following steps:
- Ø Complete Secondary Screening Questions on Page 2
- Ø Contact your County Health Department (see Page 3)
COVID-19 Secondary Screening Questions
- ü Complete a separate form for each patient, caregiver or family member who is screened
- Date of Questionnaire: _____ / _____ / _____
Patient Name: ___________________________________________________________________
Patient MRN: ____________________________________________________________________
Patient Contact Information: _______________________________________________________
Staff Member completing Questionnaire: _____________________________________________
Staff Member contact information: __________________________________________________
If phone interpreter is desired, see attached list from Language Scientific, Language Phone Interpreting
Service utilized by California Specialty
Pharmacy
Date of symptom onset ____ / ____ / _____
Does the patient have the following signs and symptoms (check all that apply)?
Fever Cough Sore throat Shortness of breath
In the 14 days before symptoms, did the patient:
Spend time in any of the following locations:
China South Korea Iran Italy Japan
What area/city (list all) ______________________________________
Does the patient live in country above? Yes No Unknown
Date traveled to ____ / ____ / _____
Date traveled from ____ / ____ / ____
Date arrived in US ____ / ____ / ____
Have close contact * with a person who is under investigation for COVID-19 while that person was ill? Yes No Unknown
Have close contact * with a laboratory-confirmed COVID-19 case while that person was ill? Yes No Unknown
*Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions (e.g., being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions, such as walking by a person, are considered low risk and do not constitute close contact
COVID-19 Clinical Staff Instructions
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Patient’s Interview Questions |
Instructions for Staff |
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If the patient has: Fever or symptoms of lower respiratory illness (e.g. cough, difficulty breathing) - AND - In the last 14 days before symptom onset, a history of travel from China, South Korea, Iran, Italy, or Japan - OR – In the last 14 days before symptom onset, close contact with a person who is under investigation for COVID-19 while that person was ill. |
Notify County Health Department:
Los Angeles County DPH Acute Communicable Disease Control: • Weekdays 8:30am–5pm: call 213-240-7941. • After-hours: call 213-974-1234 and ask for the physician on call. Orange County Public Health · 714-834-8180 Riverside County Public Health · 951-358-5000 San Bernardino County Public Health · (800) 722-4777 · After Hours: (909) 356-3805 Ventura Public Health · 805-981-5201 |
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If the patient has: Fever or symptoms of lower respiratory illness (e.g. cough, difficulty breathing, but no relevant travel history or ill close contact |
Droplet precautions for respiratory symptoms (goggles or face shield) |
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If the patient has: Travel history to China, South Korea, Iran, Italy, or Japan within the past 14 days or close contact* with a person who is under investigation for COVID-19 while that person was ill, but no symptoms |
Standard precautions |
*Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions (e.g., being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions, such as walking by a person, are considered low risk and do not constitute close contact