COVID-19 SELF-EVALUATION QUESTIONNAIRE

Rev4 2021

This questionnaire is designed to help prevent potential transmission of COVID-19 to OML34

Offices, field locations, drilling rig and to protect our employees.

All crew change personnel, visitors to OML34 Offices, field locations, drilling rig are required to
complete this questionnaire and send to your host at OML 34 for necessary advice on your visit 48hrs
prior to arrival.
Notations
All sections are mandatory.
You are kindly requested to complete this form with a firm commitment to provide accurate
information to protect both yourself and others from inadvertent exposure to COVID-19

Name (Surname First): Gender:

Contact Address: Date: Time:

Email address:

Contact phone number:

Department in OML 34:

Supervisor name:

Name of Host at OML 34(for visitors):

Host Dept and contact number:

In the table below, TICK if you have any of the Symptoms:

1. Clinical Symptoms
NO YE NO YES
S

Elevated Body Temperature/ Fever above Headache

37.7 °C (99.9 °F) i

Cough Difficulty breathing or

Shortness of breath

OML34 HSE/COV-19/004
 Sore Throat Muscle Pain

Fatigue/Malaise Loss of taste/smell

Nasal Congestion

2. Contact History
Anybody in your family with the above complaints? NO ☐YES ☐

If yes, specify........................

Have you had contact with person(s) with the above complaints in the past 2weeks? NO ☐
YES ☐
If yes, specify.......................

3. Travel history

Do you have a history of international travel in the past 4 NO YES If Yes, specify.
weeks to or from any of the following places?

Brazil

India

Turkey

China, Korea, Japan etc.

Italy, Spain, France, Germany, United Kingdom etc.

South Africa

USA

1. Have you been admitted in the hospital in the past 2 weeks? NO ☐ YES ☐
2. Have you visited anyone or family member in hospital in the past 2 weeks? NO ☐ YES
☐
3. Are you currently on any medications for fever or respiratory tract illness? NO ☐ YES
☐
4. Have you been exposed or suspect that you have been exposed to anyone with COVID-19
in the last 48hrs? NO ☐ YES ☐
5. Have you attended any event/ceremony (e.g., burial, wedding) in the last 5days where
physical distancing protocols was not observed? NO ☐ YES ☐
6. Have you been vaccinated with any of the coronavirus vaccines (e.g., 1 st dose, 2nd dose,
single shot)? NO ☐ YES ☐

Note. If the answer to any of the above-mentioned questions is YES, kindly provide further
details:
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OML34 HSE/COV-19/004
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Three non-pharmaceutical interventions for coronavirus prevention:

 Wear your facemask in public places
 Maintain physical distancing
 Wash your hands frequently with soap and water. Use alcohol-based hand sanitizer in the
absence of soap and water.

Get vaccinated at the earliest opportunity

Regards
OML 34 HSE DEPARTMENT

OML34 HSE/COV-19/004