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The Covid-19 Health Assessment form provides a quick check for staff to identify their risk and ensure you are taking the proper precautions for the safety of your business, staff, and customers.

Checklist Sections

12 Questions
Employee Data 6 Questions
short_text Template Instructions
crop_7_5 Employee First Name
crop_7_5 Employee Last Name
crop_7_5 Email
crop_7_5 Phone Number
question_answer Department
Symptoms 6 Questions
question_answer I have travelled internationally in the last 14 days.
question_answer I have had contact with someone with confirmed COVID-19 in the last 14 days.
check I have NOT experienced any health concerns in the past 14 days.
question_answer Please indicate which symptoms you have experienced in the past 14 days:
check I do NOT have any existing health conditions.
question_answer Please indicate which conditions you have been diagnosed with in the past: