Pre-Return to Scouting Questionnaire COVID-19
This questionnaire can be cut andpasted into an email and filled out and emailed to monday37thcubs@hotmail.com or printed off and filled in by hand and given to a leader before any cubs or scouters / leaders return to scouting.
If the answer is Yes to any of the below questions, you are advised to seek medical advice before returning to scouting.
Name of Scouter in Charge: Oran Doyle / Monday Night Cubs section leader
Name of Cub / Scouter :________________________
Date: ________________________
Questions - YES / NO
1.Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?
2.Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
3.Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)
4.Have you been advised by a doctor to self-isolate at this time?
5.Have you been advised by a doctor to cocoon at this time?
6.Have you been advised by your doctor that you are in an at risk group?
7.I agree to advise my Section Leader or Groups Leader (as appropriate) if I answer yes to any of the questions 1 to 6 prior to attending future meetings and activities?
I confirm, to the best of my knowledge that I have no symptoms of COVID-19, am not self-isolating or awaiting results of a COVID-19 test.
Please note: The organisation is collecting this sensitive personal data for the purposes of maintaining safety within the workplace in light of the COVID-19 pandemic. The legal basis for collecting this data is based on vital public health interests and maintaining occupational health and will be held securely for the designated 14 day minimum for contact tracing purposes and then securely destroyed.
Signed: _____________________________________
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