CCG COVID-19 DAILY SCREENING

Date Logged*

An employee must answer “NO” to all the questions in this questionnaire in order to enter the store and commence duties. If an employee experiences any symptoms or answers “YES” to any of these questions, please DO NOT allow them to enter the premises. The employee is not permitted to work and must immediately contact the COVID-19 hotline: 0800 02 9999 for instruction and direct the employee to act in accordance with those instructions.

Branch*

Choose the branch where staff member is based.

Name of person conducting screening*

Employee being screened*

Have you had close contact with someone diagnosed with COVID-19 or been notified that you may have been exposed to it?*

YesNo

Are you under investigation by the Department of Health or NICD?*

YesNo

Have you or your immediate family (that reside with you) been travelling between provinces in the last 14 days?*

YesNo

Do you have a fever (38 degree or higher), or a sense of having a fever?*

YesNo

Do you have a NEW COUGH that you cannot attribute to another health condition?*

YesNo

Do you have a NEW SHORTNESS OF BREATH that you cannot contribute to another health condition?*

YesNo

Do you have a NEW SORE THROAT that you cannot attribute to any other illness?*

YesNo

Are you experiencing FATIGUE or WEAKNESS that you cannot attribute to any other illness?*

YesNo

Do you have NEW MUSCLE ACHES that you cannot attribute to another health condition, or that may be caused by a specific activity(physical excercise) or injury?*

YesNo

Have you experienced a NEW LOSS OF SMELL and/or TASTE?*

YesNo

Do you have TIGHTNESS IN YOUR CHEST?*

YesNo

Have you experienced ANY of the following symptoms: NAUSEA; VOMITING; DIARRHEA; REDNESS OF EYES?*

YesNo, none of the above

Have you TESTED POSITIVE for COVID-19 in the past? If yes, you will need to produce a medical certificate confirming you DO NOT have an active infection of COVID-19.*

YesNo

CIRCUS CIRCUS GATEWAY is committed to employee safety and well-being and encourages employee cooperation and support in the efforts to minimize the impact of COVID-19.