Covid Screening Checklist Form Personal Information Name * First Name Last Name National ID Number * Email * Phone * (###) ### #### Questions 1. Have you had any of the following symptoms in the last 30 days: * Gastrointestinal Issues Loss of Taste/Smell Myalgia/Body Pains Shortness of Breath Quick Breathing Cold Sweats Runny Nose Sore Throat Diarrhoea Cough Fever Chills None of the Above 2. Have you, or someone in your household, had close, unprotected contact with a suspected or known COVID-19 patient (spent longer than 15 minutes within 6 feet of someone who was sick with a fever and cough)? * Yes No 3. Do you have a history of traveling to areas with local transmission of COVID-19? * Yes No 4. Did you work in, or attend a health care facility where patients with COVID-19 infections were being treated? * Yes No 5. Have you recently been admitted with severe pneumonia of unknown aetiology? * Yes No 6. Have you been tested for COVID-19 in the last 30 days? * Yes No If YES: 6.1 When they tested you for COVID-19, was the result: Positive Negative If POSITIVE: 6.1.1. Have you been quarantined and treated by the proper Health Care Practitioners & Support Teams, and then released as Completely Recovered? Yes No The information provided above is correct. * I Agree I Disagree I consent to Springfontein Estate (PTY) Ltd processing and storing my personal data. * I Agree I Disagree Information collected and stored is 100% confidential. Thank you!
