RISK SELF-ASSESSMENT

By entering the CFC facility today, I affirm that ALL the following statements are true:

1. I do not have any of the following COVID-19 symptoms*
  • Dry, persistent, non-productive cough
  • Shortness of breath or difficulty breathing that is unusual to me
  • Fever or feeling feverish
  • Chills or repeated shaking with chills
  • Repeated shaking with chills
  • Muscle pain that is unusual to me
  • Sore throat
  • New loss of sense of taste or smell

2. In the last 14 days, I have not lived with, been an intimate partner of, provided care to, or been in close contact with (within 6 feet for 15 or more minutes) a person diagnosed and on home isolation with COVID-19.

3. In the last 14 days, I have not been informed by a health care provider of the need to self-quarantine.

4. I have not traveled outside the country or been on a cruise ship or river boat in the last 14 days. If you are not able to affirm that all the above statements are true, do not enter a CFC facility; notify your Leadership. If you are not able to affirm that statement #1 (regarding COVID-19 symptoms) is true, contact your healthcare provider for a more detailed assessment of your health.

By entering the CFC facility today, I affirm that ALL the following statements are true:

1. I do not have any of the following COVID-19 symptoms*
  • Dry, persistent, non-productive cough
  • Shortness of breath or difficulty breathing that is unusual to me
  • Fever or feeling feverish
  • Chills or repeated shaking with chills
  • Repeated shaking with chills
  • Muscle pain that is unusual to me
  • Sore throat
  • New loss of sense of taste or smell

2. In the last 14 days, I have not lived with, been an intimate partner of, provided care to, or been in close contact with (within 6 feet for 15 or more minutes) a person diagnosed and on home isolation with COVID-19.

3. In the last 14 days, I have not been informed by a health care provider of the need to self-quarantine.

4. I have not traveled outside the country or been on a cruise ship or river boat in the last 14 days. If you are not able to affirm that all the above statements are true, do not enter a CFC facility; notify your Leadership. If you are not able to affirm that statement #1 (regarding COVID-19 symptoms) is true, contact your healthcare provider for a more detailed assessment of your health.