Homeless Shelter Modified Screener

DRAFT

Modification of Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

SARS-COV2 Homeless Shelter Intake Form

Interviewer Name______________________________ Location__________________________________

Participant UNIQUE ID: __________________________Date_____________________________________

Thermometer reading _____________________^oF________

Demographic information

Date of birth (MM/DD/YYYY): / /	Ethnicity: Hispanic/Latino Not Hispanic/Latino
Race: White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Other Pacific Islander
Sex: Male Female	Status: Client Staff Other Unknown

Symptoms

Symptom	Symptom Present in the last day?	Symptom Present in the last week?	Duration (days)
Fever >100.4F (38C)	Yes No Unk	Yes No Unk
Subjective fever (felt feverish, warm, chills)	Yes No Unk	Yes No Unk
Cough (new onset or worsening/change in cough)	Yes No Unk	Yes No Unk
Shortness of breath	Yes No Unk	Yes No Unk
Loss of smell	Yes No Unk	Yes No Unk
Loss of taste	Yes No Unk	Yes No Unk
Nausea	Yes No Unk	Yes No Unk
Vomiting	Yes No Unk	Yes No Unk
Diarrhea (≥3 loose/looser than normal stools/24hr)	Yes No Unk	Yes No Unk

Medical History

Pregnant	Yes	No	Unk	# of weeks or due date:
Chronic lung disease	Yes	No	Unk	Specify:
Current smoker	Yes	No	Unk	Pack/year/hx: Past Smoker:
Diabetes mellitus	Yes	No	Unk	Specify: Type I or Type II
Cardiovascular dz (incl hypertension)	Yes	No	Unk	Specify:
Renal disease	Yes	No	Unk	Specify:
Liver disease	Yes	No	Unk	Specify:
Immunocompromised condition	Yes	No	Unk	Specify:
Neuro/neurodevelopmental disorder	Yes	No	Unk	Specify:
Other chronic diseases	Yes	No	Unk	Specify:

Thank you very much for your time. If you have any questions please feel free to contact the CDC at 770-488-7100 or eocreport@cdc.gov

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Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).