Pre-Event COVID 19 Questionnaire

1

Name

First Name

Last Name

2

Email* This field is required.

* Required for Confirmation Email

3

Date of Birth

Date

4

Event Attending

5

Event Date and Start Time

Date

Hour

Minutes

6

Are you in a Vulnerable Person category as defined by NHS Guidance?

YESNO

7

Do you have any of the following symptoms of COVID 19 infection indicating an active current infection?Tick All That Apply, or NONE If You Have No Symptoms

Fever

Cough

Loss of Taste or Smell

NONE OF ABOVE

8

Have you had a positive COVID-19 Test or been contacted by NHS Track and Trace within the last 10 days and advised to self-isolate?

YESNO

9

Have you had a NEGATIVE Lateral Flow Test within the last 48 hours?

YESNO

10

Have you been vaccinated against Covid-19?

Yes - 1st Dose

Yes - 2nd Dose

No

11

In the past 10 days have you had close contact with any laboratory-confirmed COVID-19 patients when you were not wearing appropriate PPE?

YESNO

12

In the past 10 days have any of your close contacts (household or workplace) had symptoms of COVID-19 and/or tested positive for COVID-19?

YESNO

13

Please confirm that you are happy to attend the above event for Waterside EMS and you agree to follow all necessary procedures for COVID 19 Mitigation.Wearing Masks, Using Hand Sanitiser, Enhanced Cleaning Procedures etc

YESNO

14

Signature

Clear

15

THERE IS A PROBLEM WITH YOUR ANSWERPLEASE CONTACT WEMS MANAGEMENT IMMEDIATELY