ReconAfrica COVID-19 Questionnaire

COVID-19 Questionnaire

ReconAfrica
All workers and visitors who are traveling to the worksite are required to complete this form.

Whenever ANY worker arrives to work from days off or a daily home commute, that worker is required to meet with Security and an HSE Advisor to have their temperature taken and answer the questions on this checklist.
Name*

First NameSurname
Date*

DayMonthYear
Date
Email*
example@example.com
Phone Number
Employer*
Status*

Upcoming travelFirst day backDaily commuterVisitorService technicianOther
You must complete a self check to ensure you do not exhibit signs of a fever, cough, or shortness of breath.*

I completed a self check.I did not complete a self check.
Do you have a fever upon returning to work from days off or a daily home commute?*

YesNo
Have you been in contact with a person infected with or suspected of having the COVID-19 virus within the last three (3) weeks?*

YesNo
Have you been fully vaccinated.*

I have.I have NOT.
All international travellers must have a negative COVID-19 test result not older than 72 hours from country of departure or they must show proof of vaccination. All travellers who arrive in Namibia with a negative COVID-19 test result that is older than 72 hours will be placed in quarantine and tested for COVID-19 on the same day, at their own expense. Once a negative test result is received, travellers will be released from quarantine. If positive, isolation is at own expense according to isolation protocols in place.*

I understand.I do not understand.
Please notify your supervisor if you exhibit any of the above symptoms and stay home if you are sick, and promptly call a healthcare provider for advice if needed.*

I understand.I do not understand.
Signature *

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