PRELead Purpose of Questionnaire To conduct a lead investigation while taking appropriate precautions due toCOVID19DATEinitial contactDATE Within24hrs of InvADDRESSProperty Event IDInitial Informat ID: 862616
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1 PRE - Lead Investigation Questionnaire
PRE - Lead Investigation Questionnaire for Family Dwellings Purpose of Questionnaire : To conduct a lead investigation while taking appropriate precautions due to COVID - 19. DATE (initial contact) : _____________________ DATE ( Within 24hr s of Inv ) : ______________ _ ___ ADDRESS : ______________________ _______________ _______________ _ Property Event ID# _ ___ _ _________ I nitial I nformation taken by : ______ __________ __ ___ _ Follow up Information taken by: __ ___ ______________ County : _____________________ INITIAL CONTACT WITHIN 24 HRS. Name & Title of person interviewed : ___ _________________ __ ______________ __ _____ Contact person who will be present during investigation : ____________________ _____________________ _ Contact person phone number: _ ( ____ ) ______________ _ ( _____ ) ______________ What is the contact person’s relations hip, if any, to the child : __________________ ________________ _ ____ Number of adults that will be present during investigation : ____ _ _ __ _ ________ ___ __________________ Number of children that will be present during investigation: _________________ _____________________ Property: INITIAL CONTACT WITHIN 24 HRS. 1. Is the property currently vacant? Y ___N___ Y__ N__ 2. Will the dwelling be occupied during the investigation? Y ___N___ Y__ N__ 3. Is the property owner - occupied? Y ___N___ Y__ N__ Pre - Screening Related Questions: 4. In the past 2 weeks, has a household member traveled out of this Count r y ? Y ___N___ Y__ N__ 5. Has a household member recently been tested or tested positive for COVID 19 ? Y ___N___ Y__ N__ 6. In the past 1 4 days has a household member had contact with any one known to test positive for COVID - 19? Y ___N___ Y__ N__ 7. In the past 24 hours, has any household member experienced: a. Fever Y ___N___ Y__ N__ b. Cough Y ___N___ Y__ N__ c. Chills Y ___N___ Y__ N__ d. Difficulty breathing , Shortness of breath Y ___N___ Y__ N__ e. New loss of taste or smell Y ___N___ Y__ N__ Precautions : Precautions will include s ocial d istancing ( maintaining a minimum distance of 6 feet from investigation team or separation of household members in a different room ) and may include Personal Protective Equipment (PPE) be ing worn by the investigation team . Is this agreeable to the occupants? Y ___N___ Y__ N__ Face coverings may be provided to the occupants to be worn during the investigation if present. Is this agreeable to the occupants? Y ___N___ Y__ N__ 8. H ousehold members agree to maintain s ocial d istancing by : a. Dwelling unoccupied (family not present) Y ___N___ Y__ N__ b. In separate rooms ___ _ __ outside of dwelling ______ Y ___N___ Y__ N__ c. Minimum 6 feet distance separation Y ___N___ Y__ N__ d. Children monitored and kept away from inspector and equipment Y ___N___ Y__ N__ 9. Will notify health department prior to the investigation of any changes ? Y ___N___ Y__ N__ * I nformation verified on - site , day of and prior to conducting Investigation: By whom: ___________________________________ ____ Date: _____________________ COMMENTS: