I understand that I am able to continue servicing patients at this time, without interruption, but may seek/ask for coverage of select, immune-compromised patients if necessary. I agree to wear a N95 mask during all clinical visits for a minimum of 10 days post-exposure with the day of exposure being Day 0. Additionally, I agree to continue to monitor daily for symptoms and complete this form again should COVID-like symptoms present. I understand that I am encouraged to get tested for COVID 5-7 days post-exposure, but this is an optional recommendation.

I understand that I am able to continue servicing patients at this time, without interruption, but may seek/ask for coverage of select, immune-compromised patients if necessary. I agree to wear a N95 mask during all clinical visits for a minimum of 10 days post-test of the household member, with the day of testing being Day 0, and at least 10 day post-symptoms of the household member. Additionally, I agree to continue to monitor daily for symptoms and complete this form again should COVID-like symptoms present. I understand that I must get tested for COVID 5-7 days post-exposure and email my negative test results to rogena@helmshomecare.com. Should my test results come back positive, I will cease providing patient care and complete this form again.

I understand that I cannot continue to provide direct patient care at this time and it is my obligation to immediately report patient coverage needs to the Care Coordination team. I understand that I must get tested for COVID (Rapid or PCR) and cannot return to direct patient care until I have submitted my negative test to rogena@helmshomecare.com and I am symptom free for at least 48 hours. When returning to patient care (symptom-free, following my negative test), I will wear a K95 mask through Day 10 post-exposure, with the day of exposure being Day 0. If I do not get tested, I am restricted from providing patient care for a minimum of 10 days post-exposure, with the day of exposure being Day 0 and a minimum of 48 hours post-symptoms. Should my test results come back positive, I will complete this form again.

I understand that I cannot continue to provide direct patient care at this time and it is my obligation to immediately report patient coverage needs to the Care Coordination team. I understand that I must get tested for COVID (Rapid or PCR) and cannot return to direct patient care until I have submitted my negative test to rogena@helmshomecare.com and my household member and I are both symptom free for at least 48 hours. When returning to patient care (symptom-free, following my negative test), I will wear a K95 mask through Day 10 post positive test of my household member, with the day of testing being Day 0. If I do not get tested, I am restricted from providing patient care for a minimum of 10 days post positive test of my household member, with the day of testing being Day 0 and a minimum of 48 hours post-symptoms from myself or my household member. Should my test results come back positive, I will complete this form again.

I understand that I am restricted from servicing patients for a minimum of 5 days post-exposure, with the day of exposure being Day 0. I understand it is my obligation to immediately report patient coverage needs to the Care Coordination team. I agree to get tested for COVID no sooner than Day 5 and I will email my negative test results to rogena@helmshomecare.com. I can return to patient care, after my negative test results are submitted, while wearing a K95 mask during patient visits through Day 10 post-exposure. If I do not get tested, but remain asymptomatic, I can return to providing patient care after Day 10 post-exposure. Should my test results come back positive, or symptoms present during the post-exposure period, I will complete this form again.

I understand that I cannot continue to provide direct patient care at this time and it is my obligation to immediately report patient coverage needs to the Care Coordination team. I understand that I must get tested for COVID (Rapid or PCR) no sooner than Day 5, with the day of exposure being Day 0. I cannot return to direct patient care until I have submitted my negative test to rogena@helmshomecare.com and I am symptom free for at least 48 hours. When returning to patient care (symptom-free, following my negative test), I will wear a K95 mask through Day 10 post-exposure, with the day of exposure being Day 0. If I do not get tested, I am restricted from providing patient care for a minimum of 10 days post-exposure, with the day of exposure being Day 0 and a minimum of 48 hours post-symptoms. Should my test results come back positive, I will complete this form again.

I understand that I am restricted from servicing patients for a minimum of 10 days post positive test of my family member and 48 hours post family member symptoms. I understand it is my obligation to immediately report patient coverage needs to the Care Coordination team. I agree to get tested for COVID no sooner than 5 days after the positive test of my household member and no sooner than 5 days after the onset of symptoms should my household member be symptomatic. I will email my negative test results to compliance@helmshomecare.com. If I do not get tested I can only return to providing patient care 15 or more days post positive test of my family member and at least 5 days post symptoms (from my household member or myself). Should my test results come back positive, I will complete this form again.

I understand that I am expected to continue reporting to work and must wear a N95 mask while present at the office for a minimum of 10 days post-exposure. Additionally, I agree to continue to monitor daily for symptoms and complete this form again should COVID-like symptoms present. I understand that I am encouraged to get tested for COVID 5-7 days post-exposure, but this is optional recommendation.

I understand that I am expected to continue reporting to work and must wear a N95 mask while present at the office for a minimum of 10 days post positive test of my family member. Additionally, I agree to continue to monitor daily for symptoms and complete this form again should COVID-like symptoms present. I understand that I must get tested for COVID 5-7 days post-exposure and email my negative test results to rogena@helmshomecare.com. Should my test results come back positive, I will complete this form again and contact my supervisor immediately.

I understand that I cannot report to work at this time. I will discuss my workload, operational needs, and potential use of sick leave / PTO with my supervisor. I understand that I must get tested for COVID on Day 5 post-exposure and email my negative test results to rogena@helmshomecare.com. Once I have my negative results and I am 48+ hour symptom-free, I am expected to return to work and must wear a KN95 mask while present at the office for a minimum of 10 days post-exposure. Should my test results come back positive, I complete this form again and contact my supervisor immediately.

I understand that I cannot report to work at this time. I will discuss my workload, operational needs, and potential use of sick leave / PTO with my supervisor. I understand that I must get tested for COVID on Day 5 post positive test of my household member and email my negative test results to rogena@helmshomecare.com. Once I have my negative results and I am 48+ hour symptom-free, I am expected to return to work and must wear a KN95 mask while present at the office for a minimum of 10 days post positive-test of my family member. Should my test results come back positive, I complete this form again and contact my supervisor immediately.

I understand that I cannot report to work at this time. I will discuss my workload, operational needs, and potential use of sick leave / PTO with my supervisor. I understand that I must get tested for COVID on Day 5 post-exposure and email my negative test results to rogena@helmshomecare.com. Once I have my negative results, I am expected to return to work and must wear a KN95 mask while present at the office for a minimum of 10 days post exposure. Should my test results come back positive, I will complete this form again.

I understand that I cannot report to work at this time. I will discuss my workload, operational needs, and potential use of sick leave / PTO with my supervisor. I understand that I must get tested for COVID on Day 5 post-exposure and email my negative test results to rogena@helmshomecare.com. Once I have my negative results and I am 48+ hour symptom-free, I am expected to return to work and must wear a KN95 mask while present at the office for a minimum of 10 days post-exposure. Should my test results come back positive, I complete this form again and contact my supervisor immediately.

I understand that I cannot report to work at this time and must quarantine for a minimum 10 days post-positive test of my family member and at least 48 hours post symptoms (of my family member or myself). I will discuss my workload, operational needs, and potential use of sick leave / PTO with my supervisor. I must test for COVID 3-4 days prior to returning to the office and email my negative test results to rogena@helmshomecare.com. Should my test results come back positive, I will complete this form again.

I understand that I am restricted from servicing patients for a minimum of 5 days post-test, with the day of testing being Day 0. If asymptomatic, I may return to providing direct patient care on Day 6. If symptoms present during my isolation period, I will not return to providing direct patient care until I am symptom free for at least 48 hours and no sooner than Day 6. Regardless, upon my return I agree to wear a N95 mask during all patient visits through Day 10 post-test.

I understand that I cannot report to work at this time and must isolate for a minimum of 5 days post-test, with the day of testing being Day 0. I will discuss my workload, operational needs, and potential use of sick leave / PTO with my supervisor. If asymptomatic, I may return to work on Day 6. If symptoms present during my isolation period, I will not return to work until I am symptom free for at least 48 hours and no sooner than Day 6. Regardless, upon my return I agree to wear a K95 mask at the office through Day 10 post-test.