Fillable Coronavirus (COVID-19) Health Questionnaire Template (London Institute of Management and Technology)

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Coronavirus (COVID-19) Health Questionnaire Template (London Institute of Management and Technology)

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Swimmer / Swim School / Facility / Employee Information
The World Health Organisation declared the Coronavirus (COVID-19) a Global Health Emergency on the
30th January 2020 and Pandemic on 11th March 2020.
will take reasonable, proportionate steps in accordance with published
guidance, to respond to the current (known) risks associated with the virus.
It is important that any person who enters any part of the pool or venue is medically and physically t and is
not a danger to themselves or the health and safety of others. If you are not sure, you should seek medical
guidance from NHS 111 https://111.nhs.uk/covid-19/
Coronavirus (COVID-19) Health Questionnaire Template
If you answered “YES” to any of the above questions or symptoms:
(Most people with coronavirus have at least 1 of these symptoms)
• Access to the pool is DENIED
• The UK Government advises that you must self-isolate for 14 days to help limit the spread
of germs
• If you have any concerns about your health and COVID-19, please call NHS 111
• If you are tested for COVID-19 and it is conrmed, you must immediately advise
Emergency Contact Details
Name:
Relationship:
Contact Number:
Question Tick your answer
Have you travelled internationally and returned to the UK in the past 14 days
from a country outside of the government’s current common travel area?
Yes No
Have you knowingly been in contact with any person who has returned from a
country outside of the government’s current common travel area in the last 14
days?
Yes No
Have you been exposed to a conrmed case of Coronavirus? Yes No
Have you had contact with person(s) with u-like symptoms? Yes No
Do you have any of the following symptoms? (please tick all that apply)
A high temperature – this means you feel hot to touch on your chest or back
(you do not need to measure your temperature)
No Symptoms
A new, continuous cough – this means coughing a lot for more than an hour,
or 3 or more coughing episodes in 24 hours (if you usually have a cough,
it may be worse than usual)
A loss or change to your sense of smell or taste – this means you’ve noticed
you cannot smell or taste anything, or things smell or taste different to normal
I warrant that, to my knowledge, I am medically and physically t and able to undertake and participate in
swim school activities and will not be a danger to myself or to the health and safety of others.
I understand that while at the venue, participating in swim school activities (and before and after swimming),
I must ensure I undertake and comply with social distancing and exemplary hygiene measures.
I acknowledge that I undertake all activities at my own risk and the swim school have not and cannot make
any representation or guarantee that attending the venue or participating in swimming is free from risk.
I declare that all the information given in this form is true and correct:
Name:
Tick the box:
I am the Swimmer
Contact Number:
Signature:
Date:
Swimmer’s Representative
Employee
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Coronavirus (COVID-19) Health Questionnaire Template (London Institute of Management and Technology)

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Completed 31 August 2020

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