Healthcare Covid Plan

HEALTHCARE COVID PLAN

Administrative Information

Plan Prepared By:   Title:

Contact Phone:   Plan Effective Date:

Purpose and Scope

This Healthcare COVID Plan (the "Plan") sets forth facility policies, procedures, and controls to minimize transmission of SARS‑CoV‑2 among patients, visitors, and staff. The Plan applies to all personnel, contractors, vendors, patients, and authorized visitors while on facility premises or participating in facility-provided services.

Roles and Responsibilities

The Facility Director is responsible for overall implementation and enforcement. Supervisors shall ensure staff compliance with screening, testing, isolation, and reporting requirements. Infection prevention personnel shall update clinical protocols, provide training, and maintain records of exposures and tests.

Patient Information (for Patient-Specific Application of Plan)

Date of Birth:   Gender:

Phone:   Emergency Contact:   Phone:

Insurance Information

Medical History & Current Status

Screening Protocol

Prior to entry, all patients and visitors will be screened for symptoms and exposure. Indicate current symptoms (check all that apply):

Testing, Vaccination & Consent

Vaccination status (select applicable):

Vaccine Type:   Date of Most Recent Dose:

 I authorize the facility to collect respiratory specimens for SARS‑CoV‑2 testing as necessary for clinical care, screening, or outbreak control.

Isolation, Cohorting & Return-to-Care Criteria

If positive or symptomatic, individual isolation will be implemented consistent with clinical guidance. Typical isolation period (days):

Date of most recent positive test (if applicable):   Clearance test required:   If required, clearance test date:

Personal Protective Equipment & Environmental Controls

Required PPE in clinical care areas:

Visitor Policy

Visitor restrictions and requirements:

Allow visitors:   If allowed, restrictions:

Staffing, Training & Communication

Supply & Contingency Planning

Privacy, Reporting & Recordkeeping

All testing and health information will be maintained in secure medical records in accordance with applicable privacy rules. The facility will report required cases and exposures to public health authorities as required by law and will document testing, isolation, and return-to-care actions.

Acknowledgment and Certification

By signing below, I certify that the information I have provided in connection with application of this Plan to my care is true and accurate to the best of my knowledge. I acknowledge that the facility's COVID policies, including screening, testing, isolation, and PPE requirements, may be applied to me while I receive services. I understand I may be required to undergo testing and temporary isolation consistent with clinical judgment and facility protocols.

I further acknowledge that the facility will retain medical records related to COVID testing and treatment and that my data will be handled in accordance with privacy requirements. I understand I may withdraw consent for certain disclosures except where the facility is required by law to report.

Patient or Authorized Representative must complete the signature block below. If signing on behalf of the patient, state relationship and authority to act.

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