Coral Leisure Internal Audit Document

1

Name* This field is required.

First Name

Last Name

2

Date* This field is required.

3

Phone Number* This field is required.

Area Code

Phone Number

4

Email

example@example.com

5

Nausea* This field is required.

YESNO

6

Vomiting / Diarrhea* This field is required.

YESNO

7

Abdominal cramps* This field is required.

YESNO

8

Temperature / Fever of 38 degrees Celsius or higher* This field is required.

YESNO

9

New and persistent cough (not related to allergies)* This field is required.

YESNO

10

Shortness of breath (not exercise related)* This field is required.

YESNO

11

Have you been in contact with anyone in the last 14 days who are experiencing these symptoms?* This field is required.

YESNO

12

Have you recently been tested for COVID-19 and are awaiting results?* This field is required.

YESNO

13

Have you been in close contact with someone with a confirmed diagnosis of COVID-19, or is being tested for COVID-19?* This field is required.

YESNO

14

Additional InformationPlease add any information you feel is relevant to this Questionnaire.

15

Signature* This field is required.I declare that I have answered the COVID-19 Customer Screening Questionnaire to the best of my knowledge. I am also aware that physical activity may be hazardous and that there may be risk involved. I acknowledge that I participate in the use of the facilities at my own risk and take full responsibility for my actions.

Clear

16