Homeless Shelter Modified Screener

SARS-CoV-2 Epidemiologic Data Collections

9. homeless_homeless shelter modified screener_instrument_OMB (omb)_ko

Homeless Shelter Staff - Homeless Shelter Modified Screener

OMB: 0920-1297

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Modification of Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

SARS-COV2 Homeless Shelter Intake Form



Interviewer Name______________________________ Location__________________________________


Participant UNIQUE ID: __________________________Date_____________________________________


Thermometer reading _____________________oF________


Demographic information

Date of birth (MM/DD/YYYY): / /


Ethnicity: Hispanic/Latino Not Hispanic/Latino

Race: White Black/African American Asian American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Sex: Male Female

Status: Client Staff Other Unknown


Symptoms

Symptom

Symptom Present in the last day?

Symptom Present in the last week?

Duration (days)

Fever >100.4F (38C)

Yes No Unk

Yes No Unk


Subjective fever (felt feverish, warm, chills)

Yes No Unk

Yes No Unk


Cough (new onset or worsening/change in cough)

Yes No Unk

Yes No Unk


Shortness of breath

Yes No Unk

Yes No Unk


Loss of smell

Yes No Unk

Yes No Unk


Loss of taste

Yes No Unk

Yes No Unk


Nausea

Yes No Unk

Yes No Unk


Vomiting

Yes No Unk

Yes No Unk


Diarrhea (≥3 loose/looser than normal stools/24hr)

Yes No Unk

Yes No Unk



Medical History

Pregnant

Yes

No

Unk

# of weeks or due date:

Chronic lung disease

Yes

No

Unk

Specify:

Current smoker

Yes

No

Unk

Pack/year/hx: Past Smoker:

Diabetes mellitus

Yes

No

Unk

Specify: Type I or Type II

Cardiovascular dz (incl hypertension)

Yes

No

Unk

Specify:

Renal disease

Yes

No

Unk

Specify:

Liver disease

Yes

No

Unk

Specify:

Immunocompromised condition

Yes

No

Unk

Specify:

Neuro/neurodevelopmental disorder

Yes

No

Unk

Specify:

Other chronic diseases

Yes

No

Unk

Specify:

Thank you very much for your time. If you have any questions please feel free to contact the CDC at 770-488-7100 or [email protected]

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Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPham, Huong T. (CDC/OID/NCHHSTP) (CTR)
File Modified0000-00-00
File Created2021-01-14

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