Covid-19 Screening Form

Name

Phone Number

Email Address

Do you have any of the following signs or symptoms? Do you have any of the following signs or symptoms? New onset of cough Worsening chronic cough Sore throat Shortness of breath Difficulty breathing New loss or decrease in sense of taste or smell Runny nose Sneezing (not allergy related) Hoarse voice Nasal congestion Chills Headache Unexplained fatigue or malaise Difficulty swallowing Nausea/vomiting, diarrhoea, abdominal pain None of the Above

Have you travelled overseas or had close contact with anyone who has travelled overseas in the past 14 days? Have you travelled overseas or had close contact with anyone who has travelled overseas in the past 14 days?YesNo

If you have been to a country on the quarantine list you need to wait 14 days before coming to the course.

Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19? Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19?YesNo

Have you worn the appropriate PPE for you normal employment daily tasks? Have you worn the appropriate PPE for you normal employment daily tasks?YesNo

Have you received a letter from your GP telling you that you should be shielding? Have you received a letter from your GP telling you that you should be shielding?YesNo

I understand that there is an increased risk of infection from COVID19 by attending a face-to-face course and that in the event of a delegate or tutor testing positive my name may be shared with the Dept of Health. I understand that there is an increased risk of infection from COVID19 by attending a face-to-face course and that in the event of a delegate or tutor testing positive my name may be shared with the Dept of Health.I agreeI do not agree (this means you cannot attend)

Declaration - I confirm that to the best of my knowledge I do not have the coronavirus and am not due to be tested for the virus Declaration - I confirm that to the best of my knowledge I do not have the coronavirus and am not due to be tested for the virusYesNo