COVID-19 Verbal Screening and Temperature Check for Staff and Visitors v2

OMB 0970-0543 [valid through MM/DD/YYYY]

Administration for Children & Families

Office of Refugee Resettlement

COVID-19 Verbal Screening and Temperature Check

for Staff and Visitors

1. Today, or in the past 24 hours, have you had any of the following symptoms?¹ [YES/NO]

   • Fever, felt feverish, or had chills

   • Cough

   • Shortness of breath or difficulty breathing

   • Muscle aches

   • Fatigue

   • Headache

   • Sore throat

   • Congestion or runny nose

   • New loss of taste or smell

   • Gastrointestinal symptoms (i.e., nausea, vomiting, or diarrhea)

2. In the past 14 days, have you had contact with a person known or suspected to be infected with the novel coronavirus (COVID-19)? [YES/NO]

3. Are you currently under isolation requirements following a positive COVID-19 viral test result? A viral test checks samples from your respiratory system (such as swabs of the inside of the nose) and tells you if you have a current infection. [YES/NO]

4. Have you had a viral test for COVID-19, and is the result unknown/pending at this time? [YES/NO]

5. Does the staff or visitor currently have a temperature of 100°F (37.8°C) or greater? [YES/NO]

1 The list of symptoms may change as we learn more about COVID-19. Please refer to the CDC website for the most up-to-date symptom list: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to administer a COVID-19 verbal screening and temperature check to all staff and visitors before they are granted access to an ORR care provider facility. Public reporting burden for this collection of information is estimated to average 0.033 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact UCPolicy@acf.hhs.gov.

[Rev. 05/18/2021] Page 1 of 1