Coronavirus
Risk Assessment Form
Name
Email
Have you been to one of the COVID-19 affected countries in the last 14 days?
Yes No
Please specify details of the cities/countries visited in the last 14 days.
Have you been in close contact with a confirmed case of coronavirus?
Yes No
Are you currently experiencing symptoms (cough, shortness of breath, fever)
Yes No
Please specify details of the symptoms
Emergency Contact Name
Emergency Contact Phone
Area Code Phone Number
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.
Signature
Clear
Should be Empty:

Coronavirus