Staff Shift Questionnaire
Please enter your full name
First Name Last Name
Which location are you based in?
Location 1 Location 3 Location 2
Shift Date & Start Time
Year Month Day
Date
Hour Minutes AM/PM Option
Since your last day at work, have you, or any member of your household, developed the symptoms of Covid-19 or felt in any other way unwell?
Yes No
Have you recently been in contact with anyone who has exhibited any symptoms of Covid-19?
Yes No
Have you recently been in contact with anyone who has tested positive for Covid-19?
Yes No
STOP!
As you answered YES to any of the previous questions, you should return home immediately!
Do you have any questions or would you like to provide any feedback?
Should be Empty:

Staff Shift Questionnaire