COVID-19 SCREENING QUESTIONNAIRE (Cuestionario de Deteccion COVID-19) COVID-19 SCREENING QUESTIONNAIRE (Cuestionario de Deteccion COVID-19) Restaurant/Location (Localidad)*Base CampLA CommissaryTX Commissary180 Broadway2000 Ross300 S. Grand3rd & Fairfax444 S. Flower465 SF609 Main7th & FigueroaBreaBrentwoodCampbellCarlsbadCentury CityCosta MesaCulver CityDel MarDowntown - San DiegoEl SegundoLa JollaMission ValleyMarina Del ReyPalo AltoPasadenaRice VillageSacramentoSan MateoSan RamonSanta MonicaSantana RowSherman OaksStudio CityTustinUC IrvineUptown ParkWest HollywoodWestlake VillageDay/Date (Fecha):* MM slash DD slash YYYY Team Member Name (Nombre de Empleado):* First Last Temperature (Temperatura):*Please enter a number from 85 to 120.Are you sick/have flu like symptoms? [Esta enfermo/tiene sintomas parecidos a la gripe?]* Yes (Si) No (No) Fever [fiebre]?* Yes (Si) No (No) Shortness of breath or difficulty breathing [Falta de respiracion o dificultades para respirar]?* Yes (Si) No (No) Cough [tos]?* Yes (Si) No (No) Chills [escalofrios]?* Yes (Si) No (No) Muscle pain [dolor muscular]?* Yes (Si) No (No) Sore throat [dolor de garganta]?* Yes (Si) No (No) New loss of taste or smell [nueva perdida de sabor u olfato]?* Yes (Si) No (No) Are you experiencing pain or pressure in your chest? [Experimenta dolor o presion en el pecho]* Yes (Si) No (No) Are you awaiting the results of a COVID-19 test? [Estas esperando los resultados de una prueba COVID-19]* Yes (Si) No (No) Have you been informed or learned of a reason that you should take precautions due to a potential exposure to COVID-19 in the last 14 days? [Ha sido informado o se entero de una razon por la que debe tomar precauciones debido a una possible exposicion al COVID-19 en los ultimos 14 dias]* Yes (Si) No (No) Have you traveled outside of the state to another high-risk area in the last 14 days? [Ha viajado fuera del estado a otra area de alto riesgo en los ultimos 14 dias]* Yes (Si) No (No) Have you been in close contact with someone who has been in those areas and/or has been sick? [Has estado en contacto cercano con alguien que ha estado en esas areas y/o ha estado enfermo?]* Yes (Si) No (No) Are you currently in care of an individual with COVID-19? [Actualmente esta cuidando a una persona con COVID-19?]* Yes (Si) No (No) Team Member: I agree that the above information is true and correct (Acepto que la información anterior es verdadera y correcta)* Yes (Si) No (No) Manager: I agree that I have reviewed the above information and confirmed it with the team member (Acepto que he revisado la información anterior y la he confirmado con el miembro del equipo)* Yes (Si) No (No) Δ
