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Questionnaire Covid 19

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13 views1 page

Questionnaire Covid 19

Uploaded by

herve.rozec
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Appendix 1

Example of Pre-Deployment Questionnaire

1. Have you had any close contact with a person who:


♦ has a confirmed COVID-19 infection?
♦ or is under investigation for COVID-19 infection?
♦ or has had any symptoms compatible with COVID 19 infection?

☐ YES ☐ NO

2. Do you currently have? (Check all that apply):

☐ Congestion or runny nose ☐ Headache ☐ Fatigue ☐ Sneezing ☐ Sore throat ☐ Fever or chills

☐ A dry cough ☐ Shortness of breath or difficulty breathing ☐ Muscle or body aches

☐ New loss of taste or smell ☐ Nausea or vomiting ☐ Diarrhoea

3. Are you currently taking prescribed medication?

☐ YES ☐ NO

4. Have you had COVID 19 or had a positive result from a PCR or lateral flow test?

☐ YES ☐ NO

If yes, what date did symptoms disappear and/or what was the date of the last negative test result?

Date of symptoms disappearance: Date of last negative test:

5. Have you had a COVID-19 vaccination or booster?

☐ YES ☐ NO

If the answer IS “YES”,


• Which vaccine did you receive [if known]?
• Did you complete the course? [Give number of injections you received].
• Give the date of your last COVID-19 vaccine/booster injection.

Name:

Date:

NOTE: It is important that the contractor has access to suitable medical expertise that can assess the questionnaire
in the event of a positive response to any of the questions.

Up to date information on COVID-19 can be found on the World Health Organisation ‘s website:

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public

IMCA Information Note 1563 Page 12 of 16

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