COVID-19

Parent/Caregiver's Name *

First Name

Last Name

Child's Name

First Name

Last Name

Has anyone in your household experienced any of the following symptoms? *

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

None of the Above

Has anyone in your household been exposed to someone who is sick or COVID-19 positive in the past 14 days? *

Yes

No

IMPORTANT INFORMATION *

Illinois' Early Intervention Program (EITP) has given the following guidelines for in-person visits. If the following guidelines are not able to be followed, the provider has the right to leave the home immediately, and a plan will be established to conduct session/evaluation virtually. -One family member (caregiver) is allowed to be present in the immediate session area. -Masks must be worn (covering mouth and nose) by anyone over 2 years of age, unless medically or physically unable to be worn. -Provider must remain 6 feet apart from child and family member present. See attached guidelines disseminated on 9/17/2020: http://www.wiu.edu/coehs/provider_connections/pdf/20200917%20Revised%20EI%20Plan%20for%20Resuming%20In-Person%20Services-%20Final.pdf

I have read these guidelines