Volunteer Self Screening — Music Therapy

Please complete this self screening form at the beginning of EVERY DAY THAT YOU ARE SEEING CLIENTS IN PERSON and/or volunteering in person with ITNC.

If you respond “YES” to any of the following questions, please contact Carly Flaagan IMMEDIATELY. Responses will be timestamped and stored for insurance and health inspection purposes. If you have any questions, please feel free to reach out.

Thank you for your diligence in this task.

Volunteer Name

Are you having trouble breathing or have you had flu-like symptoms within the past 48 hours, including: fever, cough, shortness of breath, sore throat, body aches, chills, or fatigue?

yes

Have you, or anyone in your household, been in contact with a person that has tested positive or is in the process of being tested for the coronavirus?

yes

Have you, or anyone in your household, travelled outside of the U.S. within the last two weeks?

yes