COVID-19 Risk Assessment of Employees and Students - Faculty of Engineering
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Name *
Address *
Mobile Phone Number *
Department/Unit Name *
Name of the colleague with whom you had contact *
Date of first contact during the infection period of the index cases *
MM
/
DD
/
YYYY
Date of last contact *
MM
/
DD
/
YYYY
1) Were you wearing a mask during all interactions with your colleague? *
2) Was your colleague wearing a mask at all times during the interaction? *
3) Work Space *
Yes
No
3.1 Do you work in the same room (office/lab/workspace) as the index patient?
3.2 Is that shared work space air-conditioned?
3.3 Is that workspace poorly ventilated or crowded
4) Did you share a meal or eat in the same table with the index patient at least once during the three days before his/her sample was collected (if asymptomatic) or within three days before symptom onset or during symptoms *
5) Did you share water bottle/glasses/tea cups with the index case at least once during his/her infectious period (infectious period - three days before sample collection for asymptomatic pts, three days before symptom onset for symptomatic pts) *
6) Did you share the same transport with the index patient during his/her infectious period at least once? (infectious period - two days before sample collection for asymptomatic individuals, three days before symptom onset for symptomatic pts) *
7) Did you exchange / share personal items (pens, phones, keys, books, etc.) that may be contaminated from the index case at least once during his/her infectious period? (infectious period - three days before sample collection for asymptomatic pts, three days before symptom onset for symptomatic pts) *
8) Do you think you were “exposed” to the index case during the infectious period by any other mode please indicate E.g Either of you without masks when chatting/talking for >15mins (longer durations), and with less than one meter distance, other interaction any physical contact, used bathroom in hostels at same time as index case? *
9) Did you share a bedroom with index case during the infectious period? *
10) Gatherings *
Yes
No
10.1 Were you in a gathering (ex. Meeting/ class/ discussion/ practical) with the index case during the infectious period?
10.2 Was the room where the gathering was held filled to more than 50% of capacity
10.3 Was the room where the gathering was held air conditioned?
10.4 Was the room where the gathering was held poorly ventilated?
10.5 Was the gathering held for more than 15 mins 5
11) Please describe your interactions with the colleague confirmed to have covid-19 in your own words *
12) Are you vaccinated against COVID-19? (Vaccinated - both doses of vaccine taken) *
13) Are you taking treatment for any long term/any other illness? *
14) If Yes, please indicate the condition
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