Vaccionation Site Screening

Vaccination Site Screening

Pre-screening questionnaire for all workers at the vaccination site

Questions indicated with an * (asterisk) are required.

Select Vaccination site you are working at today *

Rosenberg Annex

Mobile Unit

Katy Mills

North Annex (Katy)

Four Corners

Fifth Street

HCC Missouri City

Other

First Name *

Enter the confirmation number shown on the Employment Incentive Program email you received.

Last Name *

Email Address *

Mobile Phone *

Position *

In the past 30 days, have you been diagnosed with COVID-19 (i.e. tested positive for COVID-19)? *

Yes

Contact with a confirmed or probable case of COVID-19

["UNPROTECTED" means that proper Personal Protective Equipment (PPE) guidelines were NOT followed (gloves, mask, eye, shield, gown, etc.). "CLOSE CONTACT" means being directly exposed to infectious secretions (e.g., being coughed on); or being within 6 feet for a largely uninterrupted or sustained extended contact period, throughout the cause of a day of approximately 15 minutes]

Have you had close unprotected contact with a confirmed or probable case of COVID-19? *

Yes

Symptom check

(Note: Symptoms of COVID-19 may appear 2-14 days after exposure to the virus) 1.Cough 2.Sore throat 3.Shortness of breath or difficulty breathing 4.New loss of taste or smell 5. Nausea or vomiting 6.Chills 7.Diarrhea 8. Repeated shaking with chills 9.Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit. 10 Muscle or body aches. 11. Congestion or runny nose. 12. Headache

Have you recently begun experiencing any of the symptoms mentioned above in a way that is not normal for you *

Yes

Please use a thermometer to take your temperature right now. Select the option that best describes your result *

99.9°F or Lower

100°F or Higher

Declaration: *

I declare the answers provided are true and accurate