DuPage Care Center Visitor Screening

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this screening form prior to your scheduled visit at DPCC.

If you don't have a scheduled appointment for a visit, please reach out to your resident's Clinical Case Manager before completing this form.
Additional screening will be required on the day of your visit.
Separate forms must be completed for each visitor no earlier the 24 hours prior to visit.

Early forms will not be accepted!

Visitor Full Name *

Address *

Phone Number *

First and Last Name of Resident Visiting: *

Date of Scheduled Visit *

YYYY

Time of Scheduled visit *

Time

Are you fully vaccinated for Covid-19? *

Fully vaccinated individuals have received their second does or single- dose vaccine greater than 2 weeks ago.

Yes

If you have not been fully vaccinated for Covid-19, Have you traveled outside of the State or Country in the last 10 Days? *

Yes-if you are answering yes, please call 630-784-4240 to speak with a clinical case manager

N/A- I am fully vaccinated

Have you tested positive for COVID 19? *

Yes

If yes, did you complete the isolation period prescribed by your health care provider?

Do you currently have symptoms of a cold or flu? *

Yes

In the past 14 days: (please read through all the choices and select all that apply) *

Regardless of my vaccination status, I have had close (within 6 feet) contact with a person who has tested positive for COVID 19? (14 Days)

I have been sick with a cold or flu (14 days)

I have been around people who have been or are sick with colds or flu (14 days)

I have had a new or worsening cough (14 days) and don't know why

I have had shortness of breath or difficulty breathing (14 days) and I don't know why

I have had congestion or runny nose (14 days) not due to allergies

I have a new loss of taste and/or smell (14 days)

I have had muscle pain not related to working out, medication, or preexisting conditions (14 days)

I have had unexplainable fatigue (14 days)

I have had chills or shaking with chills (14 days)

I have not experienced any of the above symptoms in the past 14 days

Required

In the past 7 days: (please read through all the choices and select all that apply) *

I have had a headache that is new or unusual. Headache that is not related to caffeine, dietary reasons, history of migraines, cluster or tension (7 days)

I have had a fever of 100.0 degrees Fahrenheit or more (7 days)

I have had nausea and vomiting (7 days)

I have had diarrhea (7 days)

I have not experienced any of the above symptoms in the past 7 days

Required

Map

I have reviewed the map *

Yes

Required

Please Review Visitation Guidelines

I have reviewed the Visit Guidelines and understand that I am to report to the screening area when I arrive. I will not attempt to enter the building. *

Yes

Required

Further screening will be required based on the answers to these questions.

DPCC may cancel visits with little or no notice based on a variety of reasons. Advanced notice will be provided as able.

By checking the agree box, it acts as my signature; I acknowledge that all the information contained herein is true and accurate to the best of my knowledge. *

I agree

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms