Covid-19 FormCovid Screening Form.Covid Screening Form (#10) DetailsFull NameDatePhone/MobileEmailQuestionsAre you currently experiencing any of the symptoms below? None Fever or Chills Shortness of breath or difficulty breathing Sore throat Muscle or body aches New loss of taste or smell Congestion or runny nose Nausea or vomitingHave you been overseas or interstate from Western Australia in the last 14 days? Yes NoIf Yes from where did you return to Western Australia?What date did you return to Western Australia?Have you been in close contact with someone who is a confirmed or suspect case of COVID-19 in the last 14 days? Yes NoIf you have answered Yes to the questions above, please inform staff immediately.Have you been in close contact with anyone, including family that have returned from overseas or interstate travel in the last 14 days? Yes NoIf you have answered Yes to the questions above, please inform staff immediately.Have you been advised by the Department of Health, Western Australian or Commonwealth Government to be in self-isolation? Yes NoIf you have answered Yes to the questions above, please inform staff immediately.DeclarationI have read and agree to the Terms and Conditions and Privacy PolicyI have not knowingly withheld any information relevant to this medical assessment and the information provided is true and correct. As part of the COVID-19 control measures I understand the purpose of this questionnaire.By signing this questionnaire, you are committing to notifying Access Training of any changes in your health status or responses to the above questions.Submit Form
