Daily Screening

Delta Variant Advisory: A Delta variant of the Covid-19 Virus is spreading all around the world, nation, state, and region. The best defense against the Covid-19 virus is vaccination along with screenings, masks (regardless of vaccination status), and social distancing (6 feet).

Daily screening of attendants, clients, and anyone in the home prior to performing a visit is required. The requirement to document these daily screenings has been instituted by Texas HHS and will remain in effect until further notice. Below is a form to fill out each day that will record that you are screening yourself and our client before performing a visit. Please feel free to reach out to us directly if you have any questions. You may call us at (956) 720-4490.

[[[["field21","equal_to","2"]],[["show_fields","field23,field24"]],"and"],[[["field21","equal_to","3"]],[["show_fields","field23,field24,field25,field26"]],"and"],[[["field21","equal_to","4"]],[["show_fields","field23,field24,field25,field26,field27,field28"]],"and"],[[["field21","greater_than","2"]],[["hide_fields","field23,field24,field25,field26,field27,field28"]],"and"],[[["field37","equal_to","Yes"]],[["show_fields","field35"]],"and"],[[["field21","less_than","2"]],[["set_value",null,"1",null,"field21"]],"and"],[[["field38","equal_to","Symptoms present"]],[["email_to",null,"covid@heavenlycarephc.com, pbx@heavenlycarephc.com"],["redirect_to",null,"http:\/\/heavenlycarephc.com\/screening-failed"]],"and"]]
1 Step 1
Daily Screening Form
NameFirst Last
Phone Numberwith area code
Dateof screening
Number of ClientsHow many clients
Client 1Name of 1st client
Time 1of 1st screening
Client 2Name of 2nd client
Time 2of 2nd Screening
Client 3Name of 3rd Client
Time 3of 3rd Screening
Client 4Name of 4th client
Time 4of 4th screening
Household MembersWas anyone else in the home?
Household Members Namesseparate with commas
0 /
ScreeningDid the screening success or fail

I certify that i agree to comply with agency emergency response, infection control, and screening policies. 
I certify that  prior to visits I am screening myself, the client I care for, and their household members for: 

  • New identified covid-related symptoms as updated by the CDC and Texas DSHS 
  • Fever of 100° or higher
  • Exposure to individuals either confirmed or suspected cases of Covid-19
FormCraft - WordPress form builder

Essential Services Screening Process

ATTENTION: Providers / Attendants – Prior to providing services you are required to screen yourself, our clients, anyone else in the client’s home, and anyone who comes into the home during your shift. Usage of surgical masks is mandatory while conducting work and providing services to our clients.

Did you, your clients, anyone in your client’s home, or anyone entering the clients home:

  1. Have new covid-related symptoms such as: cough, shortness of breath, chills, muscle pain, headache, sore throat, new loss of taste or smell.
  2. Have a fever of above 100.0 F° – Document temperature Daily when possible
  3. Have been in close contact with someone diagnosed with COVID-19 in the past 14 days.
  4. Have been told by a health care provider you might have COVID-19.

Please call the agency if you have any questions (956) 720-4490

COVID-19: Guidance for Community Attendants and In-Home Caregivers