CDA Covid-19 Screening Questions

Name

First

Last

Within the last 14 days, have you experienced any of the following symptoms of COVID-19 which you cannot attribute to another health condition?

Yes
No

Cough, Fever, Shortness of Breath or Difficulty Breathing, Fatigue, Muscle or Body Aches, Headache, New Loss of Taste or Smell, Sore Throat, Congestion or Running Nose, Nausea or Vomiting, Diarrhea

Updated list of symptoms can be found at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

Within the last 14 days, have you had contact with someone who is currently sick with suspected or confirmed COVID-19? (If you are FULLY VACCINATED and ASYMPTOMATIC, you may answer NO to this question.)

Yes
No

NOTE: Close contact is defined as being within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period OR had direct contact with infectious bodily fluids of the person (e.g. was coughed or sneezed on).

NOTE: You are considered fully vaccinated if it has been 2 weeks or more after your second dose in a 2-dose series or 2 weeks or more after your single dose vaccine shot. If you live in a group setting (e.g. group home), being fully vaccinated is not relevant and you would have to answer YES to the question.

Within the last 10 days, have you traveled to a US state or territory other than Pennsylvania, New York or Delaware? (If you are FULLY VACCINATED and ASYMPTOMATIC, you may answer NO to this question.)

Yes
No

NOTE: You are considered fully vaccinated if it has been 2 weeks or more after your second dose in a 2-dose series or 2 weeks or more after your single dose vaccine shot. If you live in a group setting (e.g. group home), being fully vaccinated is not relevant and you would have to answer YES to the question.

Within the past 10 days, have you traveled internationally?

Yes
No

CDC Travel Notices:

www.cdc.gov/coronavirus/2019-ncov/travelers/index.html

NJ DOH travel advisory information:

https://covid19.nj.gov/travel

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CDA Covid-19 Screening Questions

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