Appointment Tracking Form

Attachment 11

Appointment Tracking Form

Pease Study

Attention:

ATSDR is taking COVID-19 prevention measures at every step of our work in your community. The Pease Study will be conducted following all state, local, and CDC guidelines in place at the time the data collection. Pease Study team members will be monitored twice daily for fever and any COVID-19-related symptoms and will wear masks and gloves to ensure the protection of participants. Similarly, participants will be monitored for fever and COVID-19-related symptoms prior to their entry into the study office and will be asked to wear a face covering or mask. If you do not have a mask, one will be provided to you.

Upon entering the study office, the staff will check if participant is wearing a mask (will provide one if not) and take the participant temperature using no-touch thermometer:

Body Temperature: ______ ˚F

<If greater than 100.4 ˚F

Sorry, we cannot continue with your appointment today. We will reschedule it for you.

CDC guidance recommends you self-isolate at home for a minimum of 14 days. Seek immediate medical attention if you have serious symptoms. Always call before visiting your doctor or health facility.

If below 100.4 ˚F < continue with COVID Symptom check.

After temperature reading is taken:

Have you had any other symptoms related to COVID-19? These can include:

Questions on symptoms will include presence of any of the following:

• Cough

• Shortness of breath or difficulty breathing

• Fever

• Chills

• Muscle pain

• Sore throat

• New loss of taste or smell

• Exposure to people known to have disease or symptoms listed above in the last 14 days

[IF YES]: Sorry, we cannot continue with your appointment today. We will reschedule it for you.

CDC guidance recommends you self-isolate at home for a minimum of 14 days. Seek immediate medical attention if you have serious symptoms. Always call before visiting your doctor or health facility.

[IF NO]: Great, we can get started.

Adult Study ID No. |_________________| Parent Study ID No. |_________________| Child Study ID No. |_________________|	Order Assigned by Coordinator	Comments	Completed			Clinic or In-field
			Date mm/dd/yy	Time hh:mm		0 clinic 1 home
Temperature below 100.4˚F/no self-reported symptoms	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Informed Consent	1.		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Update Contact Information	2.		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Blood Draw/ Urine Collection	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Assess Current Medication	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Body Measurements	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Blood Pressure Measurements	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Questionnaire	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Neurobehavioral Battery	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Received Gift Card	9.	TOTAL AMOUNT RECEIVED: [___] $25 [___] $50 [___] $75 SIGNATURE:	|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1