COVID-19 Self-Assessment Questionnaire

Sterile Training 27-29 November 2020

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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*
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

*common symptoms

If 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.

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.

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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.

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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.

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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.

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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.

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You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation.

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You cannot attend the live program in the facility. Please contact LP3 Network to discuss your situation.

8. Please select your Lab Coat and Glove size. We will do our best to accommodate your selection.

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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
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