Page 76 - CHST Research Administration eBook 2 of 2 (Q4 2021)

Sponsor Pre-Screening Form for Site Visit
Onlyonesponsorrepresentativewillbeallowedonsite. Thesponsorrepresentativewill complete the standard pre-screening survey below prior to arriving to Children’s Health and email it to Deborah.Town@childrens.com
Name of Sponsor Representative/ Company___________________________________
Do you, or have you had, a measured temperature of 100.4 or greater or subjective fever in the past 24 hours?
Yes___ No___
Do you have difficulty breathing? Yes___ No___
Doyouhaveacough,nasalcongestionorsorethroatthatisdifferentthanyour normal baseline and with symptoms that are not mild or infrequent?
Yes___ No___
Do you have a loss of taste or smell? Yes___ No___
Do you think you have had a potential exposure to someone that has confirmed COVID-19?
Yes___ No___
Have you been told to quarantine by any public health authority including DPS or TSA?
Yes___ No___
Note: If any of the above questions are answered “yes”, the visit must be rescheduled
I attest the information above is correct:
_________________________________________________ __________________________ Name of Sponsor Representative/Visitor Date