Covid-19 Health Questionnaire - Helcat Training Ltd

Name*

First Last

Email

Enter Email Confirm Email

You will recieve confirmation of this form.

Course*

Please enter the course you are attending or enter CSCS if attending for a CSCS Card test.

Course Date*

Phone*

Employer

Are you feeling well today?*

Yes
No

2. In the past 14 days have you experienced any cold or flu-like symptoms (including fever, cough, sore throat, respiratory illness, difficulty breathing)?*

Yes
No

3. In the past 14 days have you experienced a loss or change in your sense of taste of smell?*

Yes
No

4. In the past 14 days have you been in close proximity to anyone who was experiencing any of the above symptoms (Q2 & Q3) or experienced any of the above symptoms since your contact?*

Yes
No

5. In the past 14 days have you returned from or been in close contact with anyone who has returned from a country that requires you to quarantine?*

Yes
No

In the last 14 days have you been in close proximity to anyone who has tested positive for COVID-19?*

Yes
No

Have you been out with the area in the last 14 days?

Yes
No

Tier Level

If you have been out with the area in the last 14 days, please let us know what tier level you were in.

7. Have you been tested for COVID-19 and are waiting to receive test results?*

Yes
No

Consent*

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Comments

This field is for validation purposes and should be left unchanged.

CoVID-19 Health Screening Questionnaire