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COVID19 Screening Form

  1. CITY OF MANVEL_COVID-19 SCREENING FORM

  2. COVID

  3. This form shall be used on ALL persons before entering City Hall. This form is to help identify immediate potential risk. Persons who answer “YES” to the following questions should seek further evaluation.

  4. Review and answer all questions shown below

  5. Have you traveled outside of the state of Texas within the last 14-days?

  6. No

  7. Yes

  8. Have you been in close contact with anyone who has been lab-confirmed to have COVID-19?

  9. No

  10. Yes

  11. Have you experienced any of these symptoms (within the last 5 days) that are new and not part of a chronic health condition, such as COPD or emphysema?

  12. Cough

  13. No

  14. Yes

  15. Shortness of breath or difficulty breathing

  16. No

  17. Yes

  18. Chills

  19. No

  20. Yes

  21. Repeated shaking with chills

  22. No

  23. Yes

  24. Muscle Pain

  25. No

  26. Yes

  27. Sore Throat

  28. No

  29. Yes

  30. Fever-Greater than or equal to 100.4 degrees Fahrenheit

  31. No

  32. Yes

  33. Loss of taste or smell

  34. No

  35. Yes

  36. Diarrhea

  37. No

  38. Yes

  39. FOR STAFF USE ONLY

  40. BASED UPON THE RESPONSES, THIS PERSON IS NEGATIVE FOR RISK OF COVID-19

  41. BASED UP0N THE RESPONSES, THIS PERSON NEEDS FURTHER EVALUATION

  42. Leave This Blank:

  43. This field is not part of the form submission.