"Facility Entry Screening Questionnaire for Staff & Visitors" - Maryland

Facility Entry Screening Questionnaire for Staff & Visitors is a legal document that was released by the Maryland Department of Juvenile Services - a government authority operating within Maryland.

Form Details:

  • Released on April 7, 2020;
  • The latest edition currently provided by the Maryland Department of Juvenile Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Maryland Department of Juvenile Services.

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·.
Maryland
DEPARTMENT OF
JUVENILE SERVICES
I
I
-
Facility Entry Screening Questionnaire for Staff & Visitors
Any person wanting entry to this building must answer the following questions.
For DJS Residential Facilities, no visitors are currently allowed, and all employees, vendors, or contractors on
official business must also submit to a temperature check in order to gain entry.
Staff conducting the screening and temperature checks on others shall wear personal protective equipment.
Check off Yes or No for the questions below:
QUESTIONS
Yes
No
Have you had a fever in the past 7 days?
1.
(Fever may be subjective or temperature 100 degrees or above)
2. Have you had any of the following new or worsening symptoms in the past 7 days:
chills, cough, shortness of breath, sore throat, vomiting, diarrhea, loss of
taste or smell, or other flu-like symptoms?
3. Do you feel ill now?
4. Have you been outside of Maryland in the past 14 days? (This does not include travel for
work over the border to Maryland from home in a neighboring jurisdiction)
If yes, where? ____________________ *(If yes, consult with Ms. Jackson or Dr. Maehr)
5. Have you been diagnosed with Coronavirus (COVID-19) in the past 14 days or the flu
(influenza) in the past 5 days?
6. In the past 14 days, have you had physical contact with or been in close proximity
(within 6 feet for more than 2-3 minutes) to someone with suspected or confirmed
COVID-19 without the use of personal protective equipment?
FOR DJS RESIDENTIAL FACILITIES: Check individual’s temperature
7. Is temperature 100 degrees or above? Record temperature check here: ________
Temperature done by: Forehead scanner Oral/Mouth thermometer Ear thermometer
If the answer to any of the above questions is yes OR the individual refuses to complete the
screening process, then the person may not enter the building.
*For questions, clarifications, or exceptions, call Keva Jackson (DJS Health Administrator) at 410-230-3256, Dr.
Jennifer Maehr (DJS Medical Director) at 410-262-0623, or Laura White (DJS Acting Director of Nursing) at
240-675-4208 and notify the Superintendent or designee for denied access.
Name of Individual Seeking Access (Print):_____________________________________
Access Determination: Approved
Denied
Document if further consultation obtained in determination:
Name of Staff performing the screening (Print): __________________________________
Date:________________
Time:_____________
Facility:_____________________
Rev 4/7/20
·.
Maryland
DEPARTMENT OF
JUVENILE SERVICES
I
I
-
Facility Entry Screening Questionnaire for Staff & Visitors
Any person wanting entry to this building must answer the following questions.
For DJS Residential Facilities, no visitors are currently allowed, and all employees, vendors, or contractors on
official business must also submit to a temperature check in order to gain entry.
Staff conducting the screening and temperature checks on others shall wear personal protective equipment.
Check off Yes or No for the questions below:
QUESTIONS
Yes
No
Have you had a fever in the past 7 days?
1.
(Fever may be subjective or temperature 100 degrees or above)
2. Have you had any of the following new or worsening symptoms in the past 7 days:
chills, cough, shortness of breath, sore throat, vomiting, diarrhea, loss of
taste or smell, or other flu-like symptoms?
3. Do you feel ill now?
4. Have you been outside of Maryland in the past 14 days? (This does not include travel for
work over the border to Maryland from home in a neighboring jurisdiction)
If yes, where? ____________________ *(If yes, consult with Ms. Jackson or Dr. Maehr)
5. Have you been diagnosed with Coronavirus (COVID-19) in the past 14 days or the flu
(influenza) in the past 5 days?
6. In the past 14 days, have you had physical contact with or been in close proximity
(within 6 feet for more than 2-3 minutes) to someone with suspected or confirmed
COVID-19 without the use of personal protective equipment?
FOR DJS RESIDENTIAL FACILITIES: Check individual’s temperature
7. Is temperature 100 degrees or above? Record temperature check here: ________
Temperature done by: Forehead scanner Oral/Mouth thermometer Ear thermometer
If the answer to any of the above questions is yes OR the individual refuses to complete the
screening process, then the person may not enter the building.
*For questions, clarifications, or exceptions, call Keva Jackson (DJS Health Administrator) at 410-230-3256, Dr.
Jennifer Maehr (DJS Medical Director) at 410-262-0623, or Laura White (DJS Acting Director of Nursing) at
240-675-4208 and notify the Superintendent or designee for denied access.
Name of Individual Seeking Access (Print):_____________________________________
Access Determination: Approved
Denied
Document if further consultation obtained in determination:
Name of Staff performing the screening (Print): __________________________________
Date:________________
Time:_____________
Facility:_____________________
Rev 4/7/20