COVID-19 Employee Screening Questionnaire Guideline
COVID-19 Employee Screening Questionnaire Guideline
COVID-19 Employee Screening Questionnaire Guideline
COVID-19
EMPLOYEE SCREENING QUESTIONNAIRE GUIDELINE
Contractor
Age:
(If applicable)
1.
Are you above the age of 60? Yes No
2. Have you recently travelled to any high-risk country or any high-risk area defined under the National
Yes No
Disaster Regulations? (Please ask Person on Duty to explain this question)
Have you in the past two weeks interacted with a person who has been found Covid-19 positive? Yes No
3.
If YES, provide
details.
Do you suffer from any of the following conditions in a non-medicated or non-controlled manner?
Hypertension Yes No
Diabetes Yes No
Epilepsy Yes No
4.
Asthma Yes No
TB Yes No
Pregnant Yes No
If yes and symptomatic, or any vital signs out of normal limits, refer to the medical service provider
Symptom Check
Fever Yes No
Cough Yes No
Nausea Yes No
Vomiting Yes No
Diarrhoea Yes No
Fatigue Yes No
If any symptoms are present refer the employee to the isolation area
2
National Office
1.
Temperature Measurement Result if Performed
Access issued
Assessment done by
Date
I hereby declare that all the information furnished above is, to the best of my knowledge, true and correct and that no
information has been omitted or withheld. I hereby grant …………………………..(Company Name) permission to make
use of the information contained in this document to determine my personal Covid-19 risk on site.