Covid 19 Health Questionnaire

Each staff member should complete this questionnaire before starting each shift.

Name*

First Last

Date*

From Time*

:

To Time*

:

Temperature*

Are you currently required to be in isolation because you have been diagnosed with coronavirus (COVID-19)?*

Yes
No

Have you been directed to a period of 14-day quarantine by the Department of Health and Human Services as a result of being a close contact of someone with coronavirus (COVID-19)?*

Yes
No

If you answered YES to either of the above questions you should not attend work until advised by the Department of Health and Human Services that you are released from isolation or until your 14-day quarantine period is complete. If you answered NO to the above questions, proceed to the symptom checklist below. Are you experiencing these symptoms?

Fever (If you have a thermometer, take your own temperature. You are considered to have a fever if above 37.5°C)*

Yes
No

Chills*

Yes
No

Cough*

Yes
No

Sore throat*

Yes
No

Shortness of breath*

Yes
No

Runny nose*

Yes
No

Loss of sense of smell*

Yes
No

If you answered YES to any of the above questions you should not enter your workplace (or should leave your workplace). Contact Adrian 0413 484 884, go home, and get tested for coronavirus (COVID-19). If you answered NO to all the above questions, you can enter your workplace. If you develop symptoms, stay at home and seek further advice from the 24-hour coronavirus hotline 1800 675 398 or your general practitioner.

Covid 19 Health Questionnaire

Covid 19 Health Questionnaire

Each staff member should complete this questionnaire before starting each shift.

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