COVID-19 Self-Screening Attestation
Basic Information
Last Name
First Name
Middle Initial
ACC email
ACC ID (eg. a2222222)
St. David’s HealthCare is committed to the health and safety of our patients, colleagues and community. As part of our action plan for COVID- 19, we are raising awareness of the HCA Healthcare policy on Communicable Disease which states, “colleagues who believe they are infected with the flu or another communicable illness that can be transmitted through ordinary workplace contact are strictly prohibited from coming to work.” This requirement extends to our affiliated schools and their students.
By signing this form below, you are attesting to your compliance to self- screen for communicable illness prior to reporting to our facilities and that you are symptom free.
I do not have any of the following symptoms:
fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.
I have not tested positive for COVID-19
in the past [X days/weeks] or been instructed to isolate or quarantine by a healthcare provider or public health official.
I have not been in close contact
(within 6 feet for 15 minutes or more) with someone confirmed to have COVID-19 in the past [X days].
I am fully able to participate
in work, school, or other activities without risk of exposing others to illness.
Score
If you are experiencing any symptoms as listed above, please notify your instructor that you need to stay home from clinicals and contact your healthcare provider as appropriate.
You may also be asked screening questions and have temperature taken at the designated entries of the facility.
The information provided is correct and accurate to the best of my knowledge:
I agree
Contact Information