Visitation Attestation, Congregate Settings

Visitation Attestation, Congregate Settings
Name of Visitor
First NameLast Name
Who are you visiting? Provide resident name.
First NameLast Name
Date of Visit
MonthDayYear
Date
Time of Visit
Hour Minutes
AM/PM Option
Type of visitor
Compassionate Care VisitorMedical, Dental, and Behavioral HealthcareClergyOmbudsmanHealth Care Worker not employed by the facilityRegulatory and Investigative PersonnelDesignated Essential VisitorAny Other Visitor (i.e. hairstylists, educators, entertainers, volunteers, therapy dog handlers, and family members/friends/relatives)
Type of visit
Indoor (testing may be required; refer to appendix)Outdoor (allowed only during minimal or moderate community spread; no testing required)
COVID-19 Testing Results, if applicable (for Designated Essential Visitors or Any Other Visitor). If positive, restrict entry and refer to isolation guidance.
Appropriate documentation of negative result providedSample collected at appropriate interval for Designated Essential VisitorSample collected within 48 hours of visit for Any Other Visitor
Date of sample collection
MonthDayYear
Date
Test Type
Test Result

1) Access to this facility is limited to staff and visitors who do not have signs and symptoms of possible COVID-19. (Check all that apply)*

	Yes
I do not have cough (note: a cough is defined as new onset of cough within the previous 14 days)	1
I am not experiencing any of these symptoms: shortness of breath, headache, fatigue, muscle or body aches, nausea, diarrhea, new loss of taste/smell	2
I have not had close contact with someone diagnosed with COVID-19 or with the symptoms listed above without an alternative diagnosis from a healthcare provider (e.g., influenza) in the past 14 days. Close contact includes any of the following: • You were within 6 feet of someone who has COVID-19 for a total of 15 minutes or more • You provided care at home to someone who is sick with COVID-19 • You had direct physical contact with the person (hugged or kissed them) • You shared eating or drinking utensils • They sneezed, coughed, or somehow got respiratory droplets on you	3
I have isolated in the time between when the sample was taken and the visit (Applies to Indoor Visit only)	4
I have avoided attending large gatherings in between testing and visitation (Applies to designated essential visitors only)	5
I do not have a fever over 100.4 °F	6

If you are unable to answer “Yes” to all elements of question one, please DO NOT enter the facility.

2) Help us practice good infection prevention to keep residents, visitors and staff safe. During your visit you agree to:*

	Yes
Stay in designated area for the duration of your visit	7
Not use patient facilities/restroom	8
Practice good hand hygiene before entering the facility	9
Wear a face mask at all times	10
Limit touching of surfaces to only what is necessary	11
Remain at least 6 feet from all residents and staff	12
Limit physical contact and practice good hygiene before/after any contact	13
Reach out to a staff member if you have any questions or concerns	14
Contact us if you are diagnosed with COVID-19 within 14 days after your visit	15

If you are unable to answer “Yes” to all elements of question two,
please DO NOT enter the facility.
I certify to the best of my knowledge; this information is accurate.
Signature*
Clear
Name*
First NameLast Name
Date*
MonthDayYear
Date
Should be Empty: