Shelter Staff H1N1 Form
It is imperative that all residents/clients who have flu-like symptoms be immediately isolated, given a mask
and sent to Fourth Street Clinic. Use this form to determine if this course of action is necessary and send
the form with the patient to Fourth Street Clinic. Residents will not be allowed back into the shelter without
returning with this sheet signed by a Fourth Street Clinic provider. Call (801) 949-3567 to notify the clinic
that the patient is on the way or with any questions. If client is ill after clinic hours (8am to 7pm M.-Th.,
8am to 5pm F.), complete this form and isolate the client from the general population until they can be sent to
Fourth Street the following day. If the client is very ill or in distress, call for an ER transfer.
Client & Staff Info
Date/Time: ______________________ Location: _______________________
Staff Person: _______________________ Staff Phone #: _______________________
Patient Name: ______________________ DOB: _______________________
Signs and Symptom Check List
Mask all residents during the screening process. Check the resident’s temperature. If temperature is above
100 F (37.8 C), contact Fourth Street Clinic to refer patient.
Temperature: __________________
If temperature is less than 100 F (37.8 C), ask the resident the following questions:
1. Have you felt feverish in the last four days? Yes No
2. Are you having difficultly breathing? Yes No
3. Do you currently have a cough? Yes No
4. Do you currently have body aches? Yes No
If resident does not have a temperature now, but has complained of feeling feverish in the last four days and
answered yes to one of the next three questions – Contact Fourth Street Clinic and refer patient.
FOURTH STREET CLINIC STAFF USE ONLY
Provider:__________________ Date/Time:______________
_________Patient cleared to return to shelter ______Patient not cleared to return to shelter
Course of treatment: _________________________________________________________________________
___________________________________________________________________________________________
CALL 4th Street “ON-CALL INFLUENZA PROVIDER” for referrals or questions: (801) 949-3567