Clinical Services Health Screening Survey

What center/program do you receive services? *

The Lehman Center (York)

Francis Leiter Center (Chambersburg)

The Nicarry Center (New Oxford)

Name Prefix

Parent/Guardian First Name *

Parent/Guardian Last Name *

Client First Name *

Client Last Name *

Email Type

E-mail address *

Phone Type

Phone Country

Phone Number *

Phone Extension

Date and Time of your scheduled appointment *

Have you/the client had close contact in the last 14 days with someone with a diagnosis of COVID-19? *

Yes

Are you/the client or anyone in your household awaiting COVID-19 results? *

Yes

In the past 14 days has anyone in your household tested positive for COVID-19? *

Yes

In the past 14 days, have you, the client, or anyone in your household traveled outside of the United States? *

Yes

If yes, please indicate where and when

If yes, did you/they quarantine for 14 days upon returning from the trip?

Yes

If yes, please indicate the dates of travel and if you quarantined for 14 days upon returning

Children's Aid Society Administrative Office

343 Lincoln Way West, New Oxford, PA 17350

Phone: 717-624-4461
Fax: 717-624-3011

Administrative Office

343 Lincoln Way West New Oxford PA 17350
Phone: 717-624-4461
Email: info@cassd.org

Name Prefix

First Name

Last Name *

Email Type

Email *

Phone Type

Phone Country

Phone *

Phone Extension

Chills	Sweats
Felt Feverish	Temperature greater than 100 degrees Farenheit
Loss of taste/smell	Cough
Shortness of Breath	Headache
Diarrhea	Muscle Pain
Sore Throat	Vomiting
None of the Above

Alabama	Arizona	Arkansas
California	Florida	Georgia
Idaho	Iowa	Kansas
Louisiana	Mississippi	Missouri
Nevada	North Carolina	Oklahoma
South Carolina	Tennessee	Texas
Utah	Wyoming	None of the Above/Did not travel