Oregon Community Programs

COVID-19 Health Screening


In an effort to prioritize the safety of all clients and staff, OCP is implementing additional safety measures in response to COVID-19. Before each in-person (community-based or office-based) session, you will be asked the following health screening questions. Based on your answers, the clinician may need to reschedule to transition the session to Telehealth per safety policies and procedures.


Had any recent contacts tested positive for or been diagnosed with having COVID-19?

 

Client

Anyone in the household?

 

 

If yes, when? Date

If yes, when? Date


 Have/had a recent fever (defined as above 100.4 degrees)?

 

Client

Anyone in the household?

 

 


Have a cough?

 

Client

Anyone in the household?

 


Experiencing shortness of breath or trouble breathing?

 

Client

Anyone in the household?

 

 


Experiencing persistent pain, pressure, or tightness in the chest?

 

Client

Anyone in the household?

 

 


I understand that I will be asked these questions by an OCP clinician before each clinical session while COVID-19 precautions remain in place. I attest these answers are true to the best of my knowledge.

 

Caregiver’s Name:  

Client's Name:  

Leave this empty:

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Signature Certificate
Document name: COVID-19 Health Screening
lock iconUnique Document ID: 235064e768d6392ba33152229aa178f21f612f0a
Timestamp Audit
June 9, 2020 2:38 pm PDTCOVID-19 Health Screening Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85
June 9, 2020 3:26 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 9, 2020 3:48 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 25, 2020 3:27 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 25, 2020 3:30 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 25, 2020 3:35 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 30, 2020 5:02 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 30, 2020 5:06 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
January 27, 2021 1:27 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.10.43
January 27, 2021 1:27 pm PDTOCP Admin - mindib@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.10.43
April 27, 2021 4:11 pm PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85