EmailMe Form - COVID - Protocols Refresher

Today's Date *

MM / DD / YYYY

Your Name *

Your Email

Acknowledgments *

1) I acknowledge that NYC is currently undergoing a resurge in Covid and that the chances of getting Covid this season have increased enormously.

2) I realize the choices I make regarding infection control and social distancing can affect the lives of my clients, coworkers and family.

3) I am committing to following the protocols in this form.

#1) MASKS & COVID
*********************

COVID surges are back and we need to make sure that we are following prevention protocols.

Access *

I have access to clean masks as provided and directed by Home Instead Senior Care.

I agree to call Home Instead if I do not have access to masks or gloves.

Wearing a Mask *

I agree to wear a mask outside, and whenever I am within 6 feet of client, co-workers or anyone else in the client's home.

I understand that if it is proven that I have not worn a mask within 6 feet of my client that Home Instead may terminate me immediately.

#2) COVID-19 PROTOCOLS *****************

Masks *

I understand that masks must be properly worn, placed over both nose and mouth.

Entering the Home *

Stop anyone (including yourself) who enters at the front door and direct them immediately to (i) go to the bathroom for hand washing and (ii) ask them to wear a mask if they will be within 6 ft of you or client.

Change of Clothes *

Please bring a change of clothes with you, as not to wear outside clothing within the home. If you're required to wear a uniform, please do not wear it outdoors. Change upon arrival.

Hands / Gloves *

I will wash my hands frequently during my shift, and will wear gloves during personal care tasks.

Leaving the House *

Please limit trips outside to grocery shopping, essential medical appointments, local park. Make sure to keep a distance of 6' between yourself and other people on the street and in lines.

Social Distancing *

I understand that at all times (including when I'm not working), I will protect myself by practicing social distancing, wearing a mask and following all other prevention protocols.

Monitoring *

I understand that I must notify the agency if my client shows any of the following symptoms: cough, fever, headache, body ache, new loss of taste or smell, sore throat, congestion, runny nose, gastrointestinal distress, nausea, vomiting or diarrhea.

#3) Working at a FACILITY ******************************

Facilities *

I understand that some facilities may require rapid covid tests at entry, which will be provided by their staff.

#4) MONITORING ******************************

I understand that I should notify Home Instead if I experience any of the following: *

If I have any of the following symptoms (fever, cough, shortness of breath)

If I have been exposed to a COVID positive case

Signature *

Clear

Sign your name with mouse or with your finger

Any questions? Call us at 212-614-8057 or email us at *

#1) MASKS & COVID *********************

#2) COVID-19 PROTOCOLS *****************

#3) Working at a FACILITY ******************************

#4) MONITORING ******************************

#1) MASKS & COVID
*********************