Health Screening Questionnaire

  • Each family member staying at RMHC of Nashville is required to answer the following questions and review the orientation requirements with a RMHC staff member.

    *Close contact is defined as being within 6 feet for 10 minutes or more, or living in the same household.
  • If any individual responds “YES” to any of the health questions, they should not enter the House.

    I have read and answered the above questions to the best of my knowledge. I understand that the purpose of these questions is to protect those working and staying at the Nashville Ronald McDonald House from transmission of infectious disease, which may prove life threatening to them or to members of their families who are receiving hospital care. I agree to inform the management of the house immediately if I, any member of my family or anyone staying with me develop any symptoms of an infectious disease so that appropriate arrangements can be made. I release Ronald McDonald House Charities of Nashville from all liability should I, or any person staying with me, become ill. If any member of my family should develop any of the above-mentioned diseases within two weeks after our stay, I shall notify the house. Each member of the family staying at RMHC are required to 1. Hand hygiene and respiratory etiquette 2. All families must wear a mask while in common spaces of the House. 3. Social distancing requirements including restricted use of kitchen and laundry areas. 4. No visitors or siblings at this time. 5. Use of sanitizer before entering the House. 6. Common rooms are not accessible. 7. Required wellness checks. 8. Required temperature checks. 9. Must inform RMHC staff of illnesses. 10. Review of meal service protocols. 11. Review of essential movement within the House and between House and Hospital. I acknowledge that in the current environment there are many unknowns about the COVID 19, including its methods of transmission and duration. Accordingly, I understand there are inherent risks associated with any public or quasi-public appearances and/or engagements, and to such end, I release, hold harmless and covenant not to sue Ronald McDonald House Charities of Nashville for any and all actions, causes of action, claims or damages, damages at law or inequity of whatever kind related to COVID 19, including those actions, claims or damages arising out of the acts or failure to act of RMHC of Nashville, or me, while I am a guest or occupant at Ronald McDonald House except those which are due to the gross negligence of RMHC of Nashville. During my period of stay at the Ronald McDonald House I agree to comply with any and all requirements of RMHC of Nashville related to COVID 19 including compliance with governmental directives and/or orders, use of social distancing and/or masks, immediate disclosure of symptoms and/or knowledge of possible infection, personal hygiene, etc. Should any paragraph or part of this agreement be declared unenforceable by a court of competent jurisdiction, the remaining parts or paragraphs shall remain in full force and effect. I agree that the site of any action shall be City of Nashville, TN and the law governing any such lawsuit shall be Tennessee law. The terms of this agreement shall continue and be in effect after my period of stay at the Ronald McDonald House has been completed.
  • Date Format: MM slash DD slash YYYY