Donation Screening Thank you for donating to Children’s Hospital and Medical Center. One of our top priorities as an organization is to keep our patients, families and staff safe as well as members from the community. Please complete this form the day of your assigned donation. If this form is not completed we will not be able to receive your donation. Again thank you for your donation and for your part of keeping all involved safe. Do you have any of the following symptoms? Fever of 100.0⁰ F or higher Cough Shortness of breath Sore throat Loss of taste and/or smell Headache Fatigue and/or muscle ache Congestion and/or runny nose Nausea and/or vomiting Diarrhea In the past 14 days, have you been in contact with someone who has been tested, diagnosed with, or confirmed to have COVID-19? Yes No If you have answered Yes to any of the below – We will have a staff member call you to do additional screening prior to your scheduled time of arrival. I have confirmed that all donations are new and in their original packaging: Yes I have confirmed that all donations are smoke free and free from pet dander: Yes I understand that I must wear a mask at all times when on the children’s campus and will be mindful to social distance when interacting with others: Yes Name* First Last Email* Date of Scheduled Donation MM slash DD slash YYYY Please check the box below:
