Date
Event
Name
Phone Number
1. IN THE LAST 2 WEEKS, HAVE YOU BEEN IN CLOSE CONTACT WITH ANYONE DIAGNOSED WITH COVID-19?
No
Yes
2. ARE YOU SUFFERING ANY FLU LIKE SYMPTOMS? /SYMPTOMS OF CORONAVIRUS COVID-19?
No
Yes
3. ARE YOU EXPERIENCING ANY DIFFICULTY IN BREATHING? SHORTNESS OF BREATH?
No
Yes
4. ARE YOU SUFFERING FROM A COUGH OR A SORE THROAT? OR EXPERIENCING ANY FEVER LIKE / HIGH TEMPERATURE SYMPTOMS?
No
Yes
5. ARE YOU EXPERIENCING A LOSE OF SMELL/TASTE?
No
Yes
6. HAVE YOU BEEN ABROAD (INCLUDING NORTHERN IRELAND) IN LAST 14 DAYS?
No
Yes
Status
Submit
×
OK
×