MEDISCA AUSTRALIA | Attendance List & COVID-19 Questionnaire | Analgesic Compounding Lab | 31 AUG 2022

MEDISCA AUSTRALIA | Analgesic Compounding Laboratory Training

Please complete this form to sign-in each day.

First Name *

Surname *

Job Title & Pharmacy/Practice Name *

COVID-19 Self-Assessment Questionnaire

COVID-19 Common Symptoms: Fever or chills, cough, shortness of breath or difficulty breathing.

Other Symptoms: Fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea.

If you are experiencing these common symptoms, seek medical care early and stay at home. If you are a facilitator or a program attendee, please inform any MEDISCA Australia staff. You should monitor your temperature regularly to measure your current health status.

1. Are you currently experiencing or have experienced any symptoms related to COVID-19 within the last 14 days? *

If you have answered 'Yes' to any of these questions, please call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact MEDISCA 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

If you have answered 'Yes' to any of these questions, please call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact MEDISCA to discuss your situation.

3. Have you traveled overseas recently (last 14 days)? *

Yes

No

If you have answered 'Yes' to any of these questions, please call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact MEDISCA to discuss your situation.

4. Are there any reasons, specific to you, that would prevent you from following safety protocols (e.g. wearing a face mask)? *

Yes (please contact MEDISCA and provide details)

No

5. If you develop symptoms during the course, 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? *

I Agree

6. If you test positive for SARS-CoV-2 within 14 days after a live program, do you agree to inform MEDISCA and share the results? *

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.

Declaration *

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.

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MEDISCA AUSTRALIA | Attendance List & COVID-19 Questionnaire | Analgesic Compounding Lab | 31 AUG 2022

MEDISCA AUSTRALIA | Analgesic Compounding Laboratory Training

Please complete this form to sign-in each day.

COVID-19 Self-Assessment Questionnaire

If you have answered 'Yes' to any of these questions, please call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact MEDISCA to discuss your situation.

If you have answered 'Yes' to any of these questions, please call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact MEDISCA to discuss your situation.

If you have answered 'Yes' to any of these questions, please call your health care provider or public health hotline to discuss symptoms. You cannot attend the live program in the facility. Please contact MEDISCA to discuss your situation.

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.