COVID-19 Screening Questionnaire UPDATED: March 19, 2020 The care you provide to our vulnerable seniors is so important, and in order to ensure they continue to receive services during the COVID-19 precautions, we are providing additional guidance for staff who are conducting an assessment or providing services in a home setting. To protect vulnerable seniors and their caregivers, beginning March 19, 2020, the Illinois Department on Aging (IDOA) is requiring staff to ask the questions below prior to a face-to-face visit. The screening tool should be used for the following: o To screen staff, at least 24 hours before a face-to-face contact with an older/vulnerable adult. o To screen the older/vulnerable adult at least 24 hours before a face-to-face contact.  When screening an older/vulnerable adult, the staff member should review the answers to the previous screening and ask if there have been any changes since they last reviewed the form. The staff member should document on the back of the form the date and whether there were any changes. If the participant has more than one home care aide, please ensure that notes from the screenings are shared among all the staff.  One form will be used for each participant, regardless of the number of home care aides.  If the staff member has not seen the participant for 5 days or more, they should ask all the screening questions again. Within the past 14 days: 1) Have you or someone you live with been experiencing a new fever, shortness of breath, or cough? Yes □ No □ 2) Have you or someone you live with been exposed to an individual with a positive COVID-19 diagnosis? Yes □ No □ 3) Have you or someone you live with been tested positive for COVID-19? Yes □ No □ If a participant responds “yes,” to any of the above questions the staff member must contact their supervisor for further direction.  For further guidance, please see CMS’ “Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs).”