COVID day of screening

Appendix H: COVID-19

Day of Screening Tool

OMB Control Number: 0583-xxxx
Expiration date: xx/xx/xxxx

1. Do you have a fever and/or shortness of breath, unexplained cough, extreme fatigue?

Yes Participant will be disqualified, and researcher will state: “Please contact your medical provider to discuss your needs and report your symptoms.”

No

2. Within the past 2 weeks, have you been in close contact with someone who has been diagnosed as having COVID-19 by a healthcare professional?

Yes Participant will be disqualified, and researcher will state: “Please contact your medical provider to discuss your needs and report your symptoms.”

No

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0xxx and the expiration date is 0x/xx/20xx. The time required to complete this information collection is estimated to average 1.5 hours 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.