9 Appointment tracking form 10.28.20

Attachment 9

Multi-site Study

Appointment Tracking Form

Attention:

ATSDR is taking COVID-19 prevention measures at every step of our work in your community. The Multi-site Study will be conducted following all state, local, and CDC guidelines in place at the time the data collection. Multi-site 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 (we will provide one if not) and take the participant’s temperature using a 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