COVID-19 PROTOCOLS

Patient's Name *

First

Last

For office purposes.

Checking the protocols listed below indicates your acknowledgement of these protective measures and your family's agreement to uphold them throughout your stay at RMHC *

Social distancing should be practiced when in the presence of non-family members.
Common areas (basement, playroom, living room) are temporarily closed.
Only one family at a time may be in both the laundry room and the kitchen.
Masks are required to be worn in all areas of the House outside of your private guest room.
Temperatures will be checked and logged on every person entering the House, upon each entry.
You are asked to eat either in your room or at your pre-assigned dining room table. Please dispose of any leftover food and plates in the KITCHEN trash.
If you feel ill, please report your symptoms to the House Manager or the Manager on Duty.

SYMPTOMS TO REPORT INCLUDE: *Fever higher than 99.5 F / 37.5 C *New cough or worsened chronic cough *New loss of sense of smell or taste *Upper respiratory symptoms (e.g. shortness of breath) *GI symptoms (e.g. nausea, vomiting, diarrhea) *Headache *Body aches *Fatigue

COVID-19 SCREENING QUESTIONS

Have you had any history of fever in the last 14 days? *

Yes
No

Have you had any respiratory illness such as cough or difficulty breathing in the last 14 days? *

Yes
No

In the past 14 days, have you or any household member had any contact with a known COVID-19 patient? *

Yes
No

Have you or any household member traveled to areas of suspected community spread in the last 14 days? *

Yes
No

Have you or any household member been tested for COVID-19 in the past 14 days? *

Yes
No

Are you experiencing a loss of sense of smell or taste? *

Yes
No

Lodging at the Ronald McDonald House is a privilege and not a right. All guests are expected to abide by the rules of the Ronald McDonald House AND to act responsibly and respectfully in all instances, which may not be outlined in this document. Failure to do so may result in being required to immediately vacate the House based on the discretion of management. (copy)

I have read and understood the COVID-19 Protocols.
I acknowledge these rules and will abide by them during my stay at the Ronald McDonald House.

Signature

Date signed:

Please enter in MM/DD/YEAR format (ex.: 08/14/2020)