Covid-19 Pre-Screening Form for Entrance to the Annual Hermanus Camp
If you want to enter the Annual Hermanus Camp (AHC) campsite, from the outside, then this form must be filled in less than two days before you enter. This form must be filled in again if you have been absent for more than two days.

The purpose of this questionnaire is to self-assess your risk of being infected with covid-19 and to prevent bringing the virus to Camp. You are welcome to call the National Covid-19 Toll Free Call Center (0800 029 999), Clinicians Hotline (082 883 9920) or WhatsApp Help Service (send "Hi" to 0600 123 456) to get advice.
Email address *
First name *
Surname *
Age *
Consent
While you are at Camp, we will record your temperature daily, for public health reasons. We recognize the sensitivity of personal data such as this, so we ask your consent for us to store this data. If you consent, we will store your data in a password-protected Google Sheet, which only the official temperature-recorders, and Camp decision-makers, such as the Commandant and Adjutant, will have access to. We will handle your data with care, and it will be deleted one month after Camp ends.

This will help us monitor an otherwise invisible threat, and communicate information about the real-time situation at Camp. We will publicly share the information in an anonymized format, with only the average temperature and last recorded temperature of each individual being reported, with no personal identification such as names being attached.

Under 18's require their guardian to consent (and consent is given by default if the guardian is not present). Our full health data management policy is at http://hermanuscamp.co.za/health-data-management . Queries or concerns may be sent to Aidan Horn via WhatsApp on 0872226096 , or via email at aidanhorn@gmail.com
I consent that my daily temperature reading may be stored in a dataset, which will only be viewed by the temperature recorders and Camp decision-makers, and that my data may be reported publicly in an anonymous format. This is only for the duration of the 113th Camp. Those who do not consent to the storage of their data must report their temperature to the Adjutant in person every day.
Clear selection
What is your body temperature at present? *
Screening questions *
Yes
No
Are you experiencing acute headaches recently?
Do you have a cough or a sore throat?
Are you experiencing excess sweating?
Are you experiencing shortness of breath?
Have you suffered from acute diarrhea lately?
Are you suffering from any muscle or joint pains recently?
Do you have any underlying illness/disorder that might have compromised your immune system?
Do you suspect that you have the covid-19 infection?
In the past 14 days... *
Yes
No
Have you been in close contact with someone who has covid-19?
Have you been in close contact with someone who was recently potentially exposed to covid-19?
Have you visited any areas designated as covid-19 transmission hotspots?
Have you worked at, or attended a health care facility where patients with covid-19 infections were being treated?
Have you been in self-isolation or quarantine in the past 14 days?
In the past 14 days, have you been tested for covid-19?
If you have been tested for covid-19 recently, what was the result? (Other: date you expect to receive the test result.)
Clear selection
If you answered "Yes" to any questions or if your temperature is higher than 37.4°C, you do not have permission to enter the Camp.

In such a case, contact the Camp Doctor, Roy Huson, on 0723213463.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy