COVID-19 Self-Assessment QuestionnaireThe Science of Pharmaceutical Compounding®: Non-Sterile TrainingSydney, 16-18 Oct 2020 Full Name * 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. Currently or within the last 14 days have you 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 a Medisca staff member to discuss your situation. 2. Currently or within the last 14 days 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 a Medisca staff member to discuss your situation. 3. In the last 14 days have you traveled abroad? * Yes No Call your health care provider or public health hotline. You cannot attend the live program in the facility. Stay in self-isolation in your home for the next 14 days. 4.In the last 14 days have you traveled to any hot spots areas around Australia, such as Melbourne or affected parts of NSW? * Yes No Call your health care provider or public health hotline. You cannot attend the live program in the facility. Please contact a Medisca staff member to discuss your situation. 5. 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 a Medisca staff member to discuss your situation. 6. 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 6.a - Yes * Please explain and a Medisca 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. 7. 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 Medisca of the results? * Yes No You cannot attend the live program in the facility. Please contact a Medisca staff member to discuss your situation. 8. 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 a Medisca staff member 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 MonthNov Day Day14 Year Year2024 Leave this field blank