Covid Attendance Form
Please fill out this form prior to attending the class. Temperatures will be measured and recorded at class.
Name and Surname *
ID Number *
I am attending as: *
Symptom Check *
Yes
No
Do you have a fever (above 38°C) or a history of fever and chills?
Do you have a cough?
Are you experiencing any difficulty breathing?
Are you experiencing loss of smell or taste?
Are you experiencing any body aches?
Are you experiencing any nausea, vomiting or diarrhea?
Are you experiencing fatigue or weakness?
Close contact means you were face-to-face (less than 1m) from a person, or you were in an enclosed space (car, taxi or house) with a person for at least 15 minutes.
*
Yes
No
In the last 14 days, in your community, were you in close contact or living with a person with flu like symptoms?
In the last 14 days, in your community, were you in close contact or living with a person with confirmed Covid-19 or a person under investigation for Covid-19?
Have you worked in or visited a healthcare facility where patients with Covid-19 infections are being treated?
I understand and agree to inform the instructors should I display and/or suffer from any of the above symptoms. I understand that I enter the premises at my own risk. *
Date: *
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