Visitation Attestation, Congregate Settings

Name of Visitor

First NameLast Name

Who are you visiting? Provide resident name.

First NameLast Name

Date of Visit

Date

Time of Visit

Hour Minutes

AM/PM Option

Type of visitor

Type of visit

COVID-19 Testing Results, if applicable (for Designated Essential Visitors or Any Other Visitor). If positive, restrict entry and refer to isolation guidance.

Date of sample collection

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)

Rows	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:

Rows	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

Name

First NameLast Name

Date