COVID-19 Self-Assessment QuestionnaireNon-Sterile Training 08-09 May 2021 Full Name * Job Title * Place of Work * People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness.Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:Fever or chills*Cough*Shortness of breath or difficulty breathing*FatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea*common symptomsIf you are experiencing these common symptoms, seek medical care early and stay home. If you are a facilitator or a program attendee, please inform any LP3 Network staff. You should monitor your temperature regularly to measure your current health status. Please answer all questions below. 1. Are you currently experiencing or have experienced any symptoms related to COVID-19 within the last 14 days? * Yes No Call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation. 2. Have you been in physical contact with a positive COVID-19 infected person or someone experiencing symptoms related to COVID-19 within the last 14 days? * Yes No Call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation. 3. Have you traveled abroad recently (last 14 days)? * Yes No Call your health care provider or public health hotline. You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation. 4. Do you currently have a fever? * Yes No Call your health care provider or public health hotline. You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation. 5. Are there any reasons, specific to you, that would prevent you from following the above protocols (e.g., wearing a face mask at all times)? * Yes No 5.a - Yes * Please explain and an LP3 Network staff member will contact you to discuss your personal situation. You can attend the live program in the facility, while self-monitoring your state of health. 6. If COVID-19 symptoms present themselves at a live program, do you agree to remove yourself from the program, even if the training has not concluded, seek medical attention and inform LP3 Network of the results? * Yes No You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation. 7. If you test positive for SARS-CoV-2 within 14 days after a live program, do you agree to inform LP3 Network and share the results? * Yes No You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation. submission Please review the information above and click the "SUBMIT" button below.Thank you for remaining accountable and continuing your commitment to the health and safety of one another. Authorized Signature submit * I declare that I have completed the COVID-19 Self-Assessment Questionnaire truthfully and to the best of my knowledge at the time of submission. I clearly understand that a false or misleading declaration may put other people's health at risk. Date * Month MonthOct Day Day14 Year Year2024 Leave this field blank
