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Covid-19 Staff Questionnaire
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Untitled title
Clarendon Park Primary School
Today's Date
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MM
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DD
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YYYY
Surname
*
Your answer
Name
*
Your answer
Do you have a cough?
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Yes
No
Do you have a sore throat?
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Yes
No
Do you have difficulty breathing? (Shortness of breath)
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Yes
No
Do you feel weak and tired today?
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Yes
No
Have you had close contact within the last 14 days with someone who is suspected to have COVID-19?
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Yes
No
Have you visited a healthcare facility within the last 14 days that has treated patients with COVID-19?
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Yes
No
Have you experienced any problems with tasting food and drinks normally?
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Yes
No
Have you experienced any problems with your sense of smell?
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Yes
No
Have you experienced body aches?
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Yes
No
Have you experienced nausea or vomiting?
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Yes
No
Have you experienced diarrhea?
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Yes
No
Is anyone in your household showing Covid-19 symptoms or awaiting test results?
Yes
No
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Temperature:
*
Your answer
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