Health Symptoms Checklist

Health Symptoms Checklist and Acknowledgment Agreement

Client Name:    Provider Name:

Screening Date:    Location:

WHEREAS

WHEREAS, Provider conducts health screenings, symptom assessments, and limited health monitoring services for individuals entering Provider facilities or participating in Provider programs; and

WHEREAS, Client consents to undergo such screening and to provide truthful and accurate information regarding symptoms, recent exposures, and relevant medical history for the purpose of assessing risk and protecting public health; and

WHEREAS, the parties intend by this document to record the results of the screening, set forth limited terms governing the screening service, and memorialize Client acknowledgments and certifications.

SCOPE OF WORK

Provider will conduct the screening described above which may include a verbal symptom review, temperature measurement, brief exposure interview, and written record of responses. Screening is a limited assessment and does not constitute a medical diagnosis.

HEALTH SYMPTOMS CHECKLIST

Please indicate whether you are currently experiencing any of the following symptoms (check all that apply):

EXPOSURE AND TRAVEL

Have you traveled internationally or to a high-risk area within the last 14 days?    Yes No

Within the last 14 days, have you had close contact with a person confirmed to have an infectious disease of concern?    Yes No

MEDICAL HISTORY

Please indicate any applicable underlying health conditions:

PAYMENT TERMS

Service Fee Amount:

Payment Schedule:

Late Fee (if payment not timely):

TERM AND TERMINATION

Effective Start Date:    Term End Date:

Either party may terminate this Agreement for any reason upon written notice to the other party. Notice period (days):

CONFIDENTIALITY

All information provided by Client in this screening, and any records derived from it, will be treated as confidential to the extent required by applicable law. Provider may disclose screening information to public health authorities when required by law or where necessary to protect public health. Provider will employ reasonable administrative and physical safeguards to protect the confidentiality of screening records.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state of: without regard to conflicts of law principles.

ENTIRE AGREEMENT

This document constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior discussions, understandings, and agreements. Any amendments must be in writing and signed by both parties.

CERTIFICATION

By signing below, Client certifies under penalty of applicable law that the foregoing information is true and accurate to the best of Client's knowledge. Client acknowledges that intentional falsification of screening information may subject Client to denial of services and other legal consequences. Client consents to collection and limited use of the provided information for the purposes described herein.

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