Cluster 5 Voorpos LS COVID-19 Health Questionnaire

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Cluster 5 Voorpos LS COVID-19 Health Questionnaire - 15 February 2022

Health Questionnaire: SCREENING FOR COVID-19

This questionnaire is to be completed by each person at the competition/training venue

Email *

Surname *

Name *

Please indicate your gender *

Female

Male

Please indicate the name of your school *

Please indicate your address where you will be staying during the event

Please indicate your CELLPHONE NUMBER

Please indicate your category below. *

I am an athlete (School learner)

I am an official (Teacher/AGN)

I am a coach (Teacher)

I am a spectator

Voorpos Staff Member

I am principal/deputy principal/head of sport

Do you experience the following symptom-FEVER? *

Yes

Do you experience the following symptom-SHORTNESS OF BREATH? *

Yes

Do you experience the following symptom-SORE THROAT? *

Yes

Do you experience the following symptom-LOSS OF TASTE? *

Yes

Have you tested positive for Covid-19 in the past 14 days? *

Yes

Have you been in contact with someone who tested positive for Covid-19 in the past 14 days *

Yes

A copy of your responses will be emailed to the address you provided.

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