WEEKLY C2M COVID 19 EMPLOYEE QUESTIONNAIRE

Name(Required)

Date(Required)

YesNo
⦁ Fever (>38 degrees Celsius) or a history of fever or chills?
⦁ Cough (sudden onset)
⦁ Sore throat
⦁ Difficulty breathing
⦁ Loss of smell and/or taste
⦁ Body aches
⦁ Nausea, vomiting, diarrhoea
⦁ Fatigue/weakness
YesNo
⦁ Were you in close contact or living with any of the following: a. A person with flu like symptoms or b. A confirmed COVID 19 person or a person under investigation for COVID 19? Close contact means you were face-to-face (less than 1 meter) with the person or you were in a closed space (car, taxi or house) with the person for at least 15 minutes
⦁ Have you been admitted with severe pneumonia in the last 14 days?
⦁ Have you worked in, or attended a health care facility where COVID-19 patients are treated?
⦁ Have you been tested for COVID 19 and have you received the results of the test? If so, please provide proof before entering the RAPID NETWORKS offices or before the installation at your home or business.

Declaration of Consent(Required)

Let us know what is on your mind

Name(Required)
Email(Required)

Let us know what is on your mind

Name(Required)
Email(Required)