Certification of Lack of Exposure Form

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.

Client First Name *

Client Last Name *

Caregiver Name: *

Caregiver Email *

Date * +

Have you, a member or visitor to your household, or someone you are in close contact with
(within 3 – 6 feet for over 10 – 15 minutes) experienced any of the following symptoms in the last 24-hours?
Fever (100.03 or higher) *

Yes

Have you, a member or visitor to your household, or someone you are in close contact with (within 3 – 6 feet for
over 10 – 15 minutes) experienced any new respiratory symptom such as cough or shortness of breath in the
last 24-hours?

Caugh *

Yes

Shortness of Breath *

Yes

Other

Have you, a member or visitor to your household been in a High-Risk area (area
with widespread, ongoing community transmission) in the past 14-days? As of
March 25, 2020, those include New York metro, South Korea, Iran, China and the
United Kingdom. *

Yes

Have you, a member or visitor to your household, or someone you are in close _____ Yes _____ No contact with been in close contact (within 3 – 6 feet for over 10 – 15 minutes) with a person diagnosed with COVID-19 in the past 14-days? *

Yes

Have you, a member or visitor to your household, or any close contacts been diagnosed with COVID-19, tested for COVID-19, or been told by a health care provider that you might have or have COVID-19? *

Yes

If you answered yes to any questions in 2 through 5, please contact your healthcare provider and keep Comfort Keepers abreast of the situation.

Name: *

clear

NOTE: Certification is an ongoing requirement. If there are any changes you must contact the
office prior to any visit or shift. Should you or the client develop symptoms during a visit, you must
call the office immediately as the visit will not be able to be completed.

Report abuse