COVID-19 Electronic Screening Form

Notice: This form should be completed on the day of the visit, and will be invalid if completed the day before.

You health is important to us and we must all be committed to limiting the spread of COVID-19. In order to limit the spread, we request your cooperation in completing the following questionnaire. All information will be held in confidence.

Branch Visiting*

Reason for Visiting*

Date of Visit*

Personal Information

Name & Surname*

Name Surname

ID Number*

Contact Number*

Email Address

Your results will be delivered to this email address

Declaration Questions

1. In the past 14 days, have you been in contact with a confirmed or probable COVID-19 person (other than whilst working at our Radiology Departments wearing the appropriate Medical PPE)?*

Yes
No

1. In the past 14 days, have you been in contact with a confirmed or probable COVID-19 person?*

Yes
No

2a. Have you or your partner been to any Health Care Facility during the past 14 days (as a worker, visitor or patient) where you or your partner could have been exposed to COVID-19 without wearing Medical PPE?*

Yes
No

2a. Are you or your partner a health care worker, or working at / attending a health care facility where patients are being / or could be treated for COVID-19?*

Yes
No

2b. If yes, have either of you had any symptoms of COVID-19?*

Yes
No

3a. Have you, a family member or partner been swabbed for COVID-19 within the last 14 days?*

Yes
No

3b. Was the result positive or negative?*

Positive
Negative

4. Have you visited or reside in an old age home or retirement / nursing / step-down facility where someone has tested positive or attended any gatherings, i.e. Funerals, within the last 14 days?*

Yes
No

5a. Have you experienced any of the following symptoms in the last 7 days? Cough, Sore Throat, Shortness of Breath, Muscle or Joint Pain, Sinusitis, Diarrhoea, Redness of Eyes, Nausea, Vomiting, Fatigue, Weakness, Tiredness, Persistant Headache, Pain in One Eye, Feeling of Something Stuck in Throat*

Yes
No

5b. If yes, which of the following symptoms have you experienced within the last 7 days? Please select the appropriate symptom(s)*

6. Have you had a fever in the last 7 days?*

Yes
No

7. Have you lost your sense of smell or taste during the last 7 days?*

Yes
No

8. Have you, your family member or partner seen a doctor or any health care practitioner for any of the above symptoms or have you been admitted to a hospital for any reason in the last 7 days?*

Yes
No

9. Additional Information

Please fill in any addition information you might have

Employee Declaration

As an employee, please read and consent to the following:*

Yes, I Agree

• No face-to-face meetings to be held except if permitted by Management and must then be held according to regulations.
• It is compulsory to make use of the hand sanitizers that we have made accessible and to practice safe hygiene principles.
• Physical distancing of at least 1,5 m must be adhered to at all times.
• Wearing of appropriate face masks at work is compulsory.

I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. I further undertake to inform my Line Manager/ Supervisor should I be diagnosed with COVID-19 or display COVID-19 symptoms. I will consult with my HR Manager if I wish to discuss options if I am deemed a high risk should I be diagnosed with COVID-19 (Over the age of 60, Immuno-compromised or with related co-morbidities).

Patient Declaration

As a patient, please read and consent to the following:*

Yes, I Agree

To help limit the spread of infection and for the safety of our patients, visitors and staff members we advise that we will follow appropriate protocols in your treatment by taking your answers to the above questions into account. I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. I further undertake to inform this facility should I be diagnosed with COVID-19 within the next 14 days so as to facilitate contact tracing.

Guardian / Assistant / Other Visitor Declaration

As a guardian / assistant, please read and consent to the following::*
Yes, I Agree
To help limit the spread of infection and for the safety of our other visitors and staff members we advise that should you have answered yes to any of the above questions you must refrain from entering our facility. I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. I further undertake to inform this facility should I be diagnosed with COVID-19 within the next 14 days so as to facilitate contact tracing.

COVID-19 Declaration

Please read and consent to the following:*
Yes, I have read the declaration and agree
Please note - It is a breach of the regulations published in terms of the disaster management act to make false statements in this declaration. This can result in both criminal and civil action being instituted against you, by the state and the company respectively. Correct wearing of a face mask is compulsory for the full duration of your visit!

Please Note: Your temperature will be checked before entering the department and will determine your final screening grade.

FOR OFFICE ONLY

Name of Screening Officer: _________________________________

Signature: _________________________________

Date: _________________________________

Compliance Officer Comments: _________________________________

Temperature as measured by the Compliance Officer (in degrees Celsius): ______________________ °C

Name
This field is for validation purposes and should be left unchanged.