DRAFT
SARS-COV2 Homeless Shelter Intake Form
Interviewer Name______________________________ Location__________________________________
Participant UNIQUE ID: __________________________Date_____________________________________
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 |
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 |
|
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]
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 Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |