SARS External Surveys

Division

Name of Manager

Manager Email Address

Name of Employee

Employee Email Address

Employee SID

Date (DD-MM-CCYY)

Office

Floor

1.1 COVID-19 PRIMARY SYMPTOM SCREENING (Section 21.1) - Do you currently have any of the following symptoms - Fever

Yes No

Fever - Comment

1.2 COVID-19 PRIMARY SYMPTOM SCREENING (Section 21.1) - Do you currently have any of the following symptoms - Cough

Yes No

Cough - Comment

1.3 COVID-19 PRIMARY SYMPTOM SCREENING (Section 21.1) - Do you currently have any of the following symptoms - Sore Throat

Yes No

Sore Throat - Comment

1.4 COVID-19 PRIMARY SYMPTOM SCREENING (Section 21.1) - Do you currently have any of the following symptoms - Redness of the eye(s)

Yes No

Redness of the eye(s) - Comment

1.5 COVID-19 PRIMARY SYMPTOM SCREENING (Section 21.1) - Do you currently have any of the following symptoms - Shortness of breath or difficulty breathing

Yes No

Shortness of breath or difficulty breathing - Comment

2.1 ADDITIONAL SYMPTOMS (Section 21.2) - Are you currently suffering from or displaying any of the following additional symptoms - Body Aches

Yes No

Body Aches - Comment

2.2 ADDITIONAL SYMPTOMS (Section 21.2) - Are you currently suffering from or displaying any of the following additional symptoms - Loss of smell or loss of taste

Yes No

Loss of smell or loss of taste - Comment

2.3 ADDITIONAL SYMPTOMS (Section 21.2) - Are you currently suffering from or displaying any of the following additional symptoms - Nausea

Yes No

Nausea - Comment

2.4 ADDITIONAL SYMPTOMS (Section 21.2) - Are you currently suffering from or displaying any of the following additional symptoms - Vomiting

Yes No

Vomiting - Comment

2.5 ADDITIONAL SYMPTOMS (Section 21.2) - Are you currently suffering from or displaying any of the following additional symptoms - Diarrhoea

Yes No

Diarrhoea - Comment

2.6 ADDITIONAL SYMPTOMS (Section 21.2) - Are you currently suffering from or displaying any of the following additional symptoms - Fatigue

Yes No

Fatigue - Comment

2.7 ADDITIONAL SYMPTOMS (Section 21.2) - Are you currently suffering from or displaying any of the following additional symptoms - Weakness or tiredness

Yes No

Weakness or tiredness - Comment

What is your temperature reading in degrees Celsius? (Must include a single decimal point, e.g. 37.5)

3. UNDERTAKING BY EMPLOYEE (Section 21.3) - I understand and agree to inform my employer should I display and/or suffer from any of the above symptoms in terms of Section 21.1 and/or Section 21.2 whilst being on duty.

Yes No

COVID-19 Directive On Health And Safety In The Workplace Symptom Screening

COVID-19 Directive On Health And Safety In The Workplace Symptom Screening