"Facility Visitor Screening Questionnaire" - New Mexico

Facility Visitor Screening Questionnaire is a legal document that was released by the New Mexico Department of Health - a government authority operating within New Mexico.

Form Details:

  • Released on March 6, 2020;
  • The latest edition currently provided by the New Mexico Department of Health;
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V. 03.06.20
NEW MEXICO DEPARTMENT OF HEALTH
FACILITY VISITOR SCREENING QUESTIONAIRE
In response to concerns regarding COVID-19 (coronavirus disease 2019), and in accordance with
guidance issued by the Centers for Disease Control (CDC), this facility is screening all visitors for
certain risk factors before entrance is allowed. Facilities may restrict or limit visitation rights for
reasonable clinical and safety reasons, specifically to prevent community associated infection or
communicable disease transmission to the residents. See 42 CFR §483.10(f)(4).
Please answer the following questions and certify your answers by signing below:
QUESTIONS
YES
NO
1. Have you traveled internationally in the last 14 days to any
country currently designated by the CDC as a high-risk location
for COVID-19*?
2. Have you had signs of a respiratory infection in the last 14 days,
such as a fever, cough and/or sore throat?
3. Have you had contact with anyone who has been diagnosed with, or
screened for COVID-19?
4. Have you traveled to another state with widespread community
transmission of COVID-19 in the last 14 days?
Name:
Signature:
Date:
*As of 3/5/2020 The Center for Disease Control lists China, Iran, South Korea, Italy, and Japan.
https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html
V. 03.06.20
NEW MEXICO DEPARTMENT OF HEALTH
FACILITY VISITOR SCREENING QUESTIONAIRE
In response to concerns regarding COVID-19 (coronavirus disease 2019), and in accordance with
guidance issued by the Centers for Disease Control (CDC), this facility is screening all visitors for
certain risk factors before entrance is allowed. Facilities may restrict or limit visitation rights for
reasonable clinical and safety reasons, specifically to prevent community associated infection or
communicable disease transmission to the residents. See 42 CFR §483.10(f)(4).
Please answer the following questions and certify your answers by signing below:
QUESTIONS
YES
NO
1. Have you traveled internationally in the last 14 days to any
country currently designated by the CDC as a high-risk location
for COVID-19*?
2. Have you had signs of a respiratory infection in the last 14 days,
such as a fever, cough and/or sore throat?
3. Have you had contact with anyone who has been diagnosed with, or
screened for COVID-19?
4. Have you traveled to another state with widespread community
transmission of COVID-19 in the last 14 days?
Name:
Signature:
Date:
*As of 3/5/2020 The Center for Disease Control lists China, Iran, South Korea, Italy, and Japan.
https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html