Covid 19 employee screening

1. [COMPANY LOGO]
DOC NO 001
REV DATE 2021/04/30
ISSUED 2020/05/01
PAGE 1 of 1
SECTION RISK MANAGEMENT
SUB-SEC HSE GUIDELINES
SUBJECT COVID-19 EMPLOYEE SCREENING QUESTIONNAIRE
You are important to us and all employers should be committed to limiting the spread of COVID-19.
In order to limit the spread, we would appreciate it if you could disclose the following information. All
information will be held in confidence.
Name: Surname:
Contact Number Contact Email:
Department:
Employee Declaration Questions Yes No
1 Have you travelled in the last 21 days?
If, yes where to?:
2 Have you been exposed to someone who has the COVID-19 virus?
3 Have you experienced at least one of the following symptoms recently
a Cough
b Sore throat
c Shortness of breath
d Redness of eyes
e Body aches
f Loss of smell
g Loss of taste
h Nausea
i Vomiting
j Diarrhoea
k Fatigue
l Weakness
m Tiredness
n Fever (Must be equal to or below 37.5°C (measured))
o Fever or history of fever (subjective) over the past 21 days
4 Have you attended a health care facility where patients with COVID-19 infections
are being treated?
5 Have you been hospitalised recently with severe pneumonia?
6 Do you currently have flu like symptoms?
Please note the following which will apply to all meetings;
I hereby declare to the best of my knowledge that the information disclosed is correct at the time of
completion. I further undertake to inform my Line Manager/ Supervisor should I be diagnosed with
COVID-19 or display COVID-19 symptoms.
Your cooperation is appreciated.
Employee: Date:
Screener: Date:

2. Temperature as measured by the screener (degrees C)