Staff Questionnaire
Full name
*
First Name
Last Name
Temperature
*
Please see staff if your temperature is over 37.3
Have you
*
Yes
No
Do you have any symptoms of COVID-19?
Cough, Sore throat, Shortness of breath, Change in sense of smell or taste, Chills or sweats, Runny nose
Have you had a Rapid Antigen Test prior to the start of your shift?
What was the result of your Rapid Antigen test prior to the start of your shift? Yes (for positive) and No (for negative)
Within the last 7 days have you been diagnosed with COVID-19, had close contact with a person with COVID-19
If you have been diagnosed with COVID-19 or required to isolate for any reason, have you been given clearance from isolation?
Are you awaiting PCR COVID-19 Results? Is anyone you live with at home awaiting a PCR COVID-19 test result or been asked to isolate?
Acknowledgement
*
I agree that all the above information is true and correct
Signature
*
Submit
Should be Empty: