!

The safety of our

employees, clients,
families and visitors
COVID-19
Client & Employee Screening Questionnaire
To prevent the spread of COVID-19 and reduce the potential risk of exposure to our
workforce and visitors, we are conducting a simple screening questionnaire. Your
participation is important to help us take precautionary measures to protect you
remains our overriding and the people with whom you may interact. Thank you for your time.
priority. As the
COVID-19 outbreak
continues to evolve
and spreads globally, Name & Surname
we are monitoring
the situation
closely and will Personal Phone Number
periodically update
the recommended
operating guidelines Physical Address
based on the current
recommendations
from the World Health
Organisation (WHO). No:
Have you returned from another country
Yes:
within the last 14 days?
If yes, please specify which country:

No:
Have you been in contact with anyone who
Yes:
has travelled within the last 14 days?
If yes, please specify which country:

Have you experienced any cold or flu-like

No:
symptoms in the last 14 days (to include mild
fever, cough, sore throat, respiratory illness,
Yes:
difficulty breathing)?

Have you had close contact with someone No:

diagnosed with COVID-19 within the last 14
days? Yes:

Did you sanitize or wash your hands when

If not, please do so now
you entered?

Are you familiar with the best practices for If not, please familiarise yourself with these
coughing, sneezing and hand washing, as practices (found in the appendix below)
recommended by WHO? ahead of the appointment date in question.

Date:_______________________

NOTE: In the interest of containing the spread of this disease, if the answer is “yes” to any
question from 1-4, we hold the right not to proceed with the appointment and may suggest
an online alternative (virtual tour, WhatsApp call, email, etc.) if this option is available.
Appendix