In an effort to determine if there is a heightened risk of exposing clients or caregivers to
the novel coronavirus/COVID-19, we require that you complete this form. For employees,
the information will be used to determine whether you might pose a heightened risk of
transmitting COVID-19 such that you cannot currently interact with clients. For clients, the information will
be used to determine whether any of you might pose a heightened risk of transmitting COVID-19 such that
we cannot provide you with services at this time. We value our relationship with you and will attempt to
refer you to a Home Health Agency with the training and ability to help with communicable diseases
should you need to continue care while you still test positive for COVID-19.