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Coronavirus Screening
Please complete the screening below within 48 hours.

Thank you!

Response was added on 10/15/2020 12:03pm.

Please complete the following coronavirus screening questions and sign.

Name Habib, sarmad

(Last, First)

Within the past 14 days, have you experienced symptoms Yes

associated with Covid-19? No
(examples: fever, diarrhea, cough, shortness of
breath, muscle pain, headache, sore throat, loss of
taste or smell)

Within the past 14 days, have you been exposed to Yes

someone with a confirmed diagnosis of Covid-19 or No
someone who was under investigation for Covid-19?

Within the past 14 days, have you traveled to or from Yes

NY, NJ, CT, LA or an International location? No

As a (Student/Faculty) Cleveland Clinic caregiver, I

pledge to avoid, through appropriate and responsible
behaviors like hand washing, social distancing, and
mask wearing, the transporting of COVID-19 or any
other transmissible pathogens from my personal private
surroundings to my professional workplace in order to
protect myself, my family, all patients and every
other caregiver. I understand that by electronically
signing this document by typing my full name below,
that I acknowledge, agree and attest that the
information provided by me is true and correct and I
am freely intending to create and adopt as my own a
legally binding electronic signature that carries the
same legal effect and enforceability as my handwritten
signature.

Additionally, by signing I agree to immediately advise

my education coordinator, preceptor and academic
institute of any circumstance that would change my
answer in one or more of the above questions from the
time of signing to the end of my rotation at Cleveland
Clinic.

10/15/2020 12:03pm projectredcap.org