Staff Name:

Membership No:

Club:

Have you been in contact with a case of COVID-19?
NoYes

Have you been contacted by a member of public health about a recent case of COVID-19?
NoYes

Do you have now, or have you had in the last 24 hours, any of the following symptoms? :

Cough
NoYes

Fever
NoYes

Shortness of breath
NoYes

Excessive fatigue/tiredness (out of proportion to normal)
NoYes

Sore throat
NoYes

Loss or change to your sense of smell or taste?
(This means you've noticed you cannot smell or taste anything, or things smell or taste different to normal)
NoYes

Temperature:
Please take your temperature and write it down here:
(Please alert Covid Club Lead if this is more than 38 degrees celcius)

Date:

Signed:
[radio* signed id:signed class:signed label_first default:1 "No" "Yes"]