Phoenix Counseling Center
Employee COVID-19 Screening

**The safety of PCC employees is our overriding priority. As the pandemic continues, we are monitoring the situation closely and following the guidance from the CDC and Oregon Health Authority. In order to reduce the risk of exposure to our staff, we are asking everyone to complete and submit this screening prior to coming to work in the buildings each day.**

Please complete each section by selecting the applicable YES or NO option.

  1. Within the past 14 days have you experienced any 2 or more of the following symptoms that are not attributable to another diagnosed physical problem?

Fever above 100.4; cough; shortness of breath/difficulty breathing; sore throat; new loss of taste or smell; chills; head/muscle aches; nausea/diarrhea/vomiting.

2. Within the past 14 days have you:

Been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? (Close proximity is defined as being within 6 feet of someone for 15 minutes or more over a 24 hour period.)
Been in close proximity to anyone who has tested positive for COVID-19?
Been tested for COVID-19 and are waiting to receive test results?
Tested positive for COVID-19, or are you presumptively positive based on your health care provider’s assessment of your symptoms?
Been on a commercial flight or traveled outside of the US, or been in close proximity to anyone who has?

I, by typing my name below, certify that the responses provided above are true and accurate to the best of my knowledge.