DRLC Coronavirus COVID-19 Visitor Screening
Please complete and return this form PRIOR TO ENTRY.
Visitor Details
Location:
Des Renford Leisure Centre
Full Name (first and last):
Contact Number:
Date:
1. Have you travelled overseas in the last month? Yes No
If you answered ‘Yes’ to Question 1.
2. Please specify below details of Countries and Cities travelled to and associated dates?
3. Have you had any symptoms of the flu, virus or any other illness? eg. fever, cough,
shortness of breath, body aches, runny nose, fatigue and/or breathing difficulties.
If the answer is ‘yes’ please provide details below.
Yes No
4. Have you come into direct contact with anyone who is under investigation or self-
isolation in relation to Covid-19 in the past 14 days or would answer ‘Yes’ to any of
the above questions in section 3?
If the answer is ‘yes’ please provide details below, including detail of interaction.
Yes No
5. In the past 14 days have you been in close contact with anyone whose ability to
attend work, or associate with the public, has been restricted by a government
authority?
If the answer is ‘yes’ please provide details below.
Yes No
If you have answered yes to any of questions 1 to 5 above then PLEASE DO NOT ENTER DRLC WITHOUT
DISCUSSING YOUR ANSWERS ABOVE WITH A DRLC REPRESENTATIVE.
If you are a regular visitor to any RCC location then please ensure you advise your RCC representative, prior to
attending a site, where your answers to the above change.
I acknowledge that the information provided is true and correct and that any evidence provided is a true copy of the
original.
Full Name:
Signature:
Date:
click to sign
signature
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