COVID-19 Health declaration

UniCredit Strategy Day and Colleague Event

COVID-19 Health Declaration. Please complete this declaration each morning before leaving your hotel room or entering UniCredit Tower Hall
Consent & validation

I certify to the best of my knowledge that this information is accurate. I consent to have my temperature verified with a non-contact thermometer by a COVID officer on entry to UniCredit's offices. I agree to comply with all COVID prevention measures put in place by BvG, UniCredit and the Italian Government.
Date of completion

JourMoisAnnée
Date and time form was submitted

DayMonthYear
Personal details

Please enter your contact details below
Name*

First nameLast name
Mobile / Cell phone number
Number including country code
Email*
example@example.com
IMPORTANT

The purpose of this questionnaire is to minimize the risk of spreading the COVID virus during Strategy Day and the Colleague Event. It is important to answer the questions accurately.

Some answers may limit your access to UniCredit Tower Hall or require further clarification.
Questions and declaration
1. Have you taken a self-administered lateral flow test this morning? *

Yes No

Test taken?
You must take a test before continuing. Come back to this form once you have taken a self-administered lateral flow test.
Was the result positive or negative?*

PositiveNegative

Result symptoms Type B
4. In the past 14 days, have you been in contact with a suspected COVID-19 positive?*

YESNO
If you answered YES to question 4, please specify the type of contact:

Close contact: for more than 15 minutes in 24 hours cumulatively to less than 2m?Close contact: sharing an enclosed space for more than two hours (bedroom, office, car, etc )Occasional contact: less than 15 minutes of face-to-face contact with a confirmed COVID+ case in the 24 hours prior to the onset of symptoms.Occasional contact: sharing an enclosed space with a confirmed COVID+ case for less than two hours in the 24 hours prior to the onset of symptoms.
5. In the past 14 days, have you been in contact with a confirmed case of COVID-19 positive?*

YESNO
If you answered YES to question 5, please specify the type of contact:

Close contact: for more than 10 minutes cumulatively to less than 2mClose contact: sharing an enclosed space for more than two hours (bedroom, office, car, etc )Occasional contact: less than 15 minutes of face-to-face contact with a confirmed COVID+ case in the 24 hours prior to the onset of symptoms.Occasional contact: sharing an enclosed space with a confirmed COVID+ case for less than two hours in the 24 hours prior to the onset of symptoms.
6. Have you been diagnosed with COVID-19 in the last 14 days or do you think you may have it?*

YESNO
How was the diagnosis made?
Date of onset of symptoms

MonthDayYear
Date
Date of diagnostic test

MonthDayYear
Date
REMINDER
It's important to:
- wash your hands frequently with soap or use hand sanitiser
- wear a face covering when indoors or near groups of people
- note that in Italy it is the law to wear a mask indoors
Signature*

Clear
Should be Empty:

	YES	NO
Fever ( 38 C or higher) or feeling of fever (chills)
Cough (new or exacerbation of a chronic cough)
Difficulty breathing or chest pain
Loss of sense of smell or taste without nasal congestion

	YES	NO
Major fatigue
Headache
Congestion / runny nose
Gastroenteritis (nausea, vomiting, diarrhoea)

UniCredit Strategy Day and Colleague Event

Consent & validation

Personal details

Questions and declaration

REMINDER