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
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?
Submit
Should be Empty: