FIAO Health Screening Questionnaire

FIAO Health Screening Form for entering Il Centro Facility

At FIAO, the health and safety of our Members and Staff remains our top priority. We continue to closely monitor guidance from the CDC along with the federal, state, and local directives. Our approach to the situation continues to be with an abundance of caution to ensure the safety of all. We ask for your support in the shared responsibility to minimize the risk of exposure and to protect our individual and collective health. To that end, all Staff and Visitors to our office, school sites and center need to complete the short Questionnaire below. For everyone whose response on any of these questions is YES than as a precautionary measure, she/he will be UNABLE to continue with their visit to FIAO and the staff or visitor will be asked to please make alternative arrangements with FIAO. The visitor’s answer below needs to be verified, signed off with a date and retained at the site in an accessible file for future reference if needed. Thank you for your understanding and cooperation. (Questions with an* are mandatory)

Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath that started in the past 10 days?*
- YES
- NO
In the past 10 days, have you gotten a lab-confirmed positive result from a COVID-19 test that was your first positive result OR was AFTER 90 days from your previous diagnosis date? Please note that 10 days is measured from the day you were tested, not from the day when you received the test result.*
- YES
- NO
Are you considered fully vaccinated against COVID-19 by CDC guidelines OR were you recently (within the past three months) diagnosed with COVID-19 and finished isolation in the past 90 days AND you have not traveled internationally in the past 10 days? Please note that to be considered fully vaccinated by CDC guidelines, two weeks must have passed since you received the second dose in a two-dose series or two weeks must have passed since you received a single-dose vaccine.*
- YES
- NO
To the best of your knowledge, in the past 10 days, have you been in close contact with anyone confirmed or presumed positive for COVID-19?*
- YES
- NO
Did you, or anyone in your immediate household, travel internationally or travel on a cruise ship in the past 10 days?*
- YES
- NO
Reason for Visit:*
- Social Services with Sara
- Tour of the Facility
- Member
- Scheduled Meeting
- Staff
- Event
Email
Phone Number*
DIGITAL SIGNATURE OF MEMBER/VISITOR:*
(PLEASE TYPE NAME)
First Last