COVID-19 SCREENING QUESTIONNAIRE AND CASE REPORT FORM

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DELI-GEN-DEL-HS-FRM-0003_R5 27-OCT-2021

COVID-19 SCREENING QUESTIONNAIRE AND CASE REPORT FORM

PLEASE COMPLETE AND RETURN TO DENOVO HSSE.

All persons requiring DeNovo sites access, Shall submit a COVID – 19 Screening Questionnaire and Case Reporting Form 24hrs. before arrival at site. In addition, all persons will be subjected to COVID – 19 screening on arrival.

DENOVO CONTACT / REPRESENTATIVE INFORMATION

(This is the name and details of DeNovo authority that is accountable for the activity that you will be executing at DeNovo’s facility)

DeNovo’s Contact Full Name *

Date

2023-03-24

DeNovo Rep.'s Tel.
Contact Number *

DeNovo Rep.'s
Email *

Department

DeNovo Facility

1 DeNovo Place

GPU

Iguana NUI

Zandolie

Purpose of Visit

Date of Visit

Comments

PERSONAL INFORMATION

Your Name

Date of Birth

Gender

Tel. Contact Number

Place of Residence (City/Town and Country)

Your Email

Company

Nationality

National ID

Emergency Contact*

* Who should we contact in the event you experience a medical emergency. (e.g. NOK, Company Representative, Line Manager or Supervisor)

1. Please list ALL countries visited in within the last twenty-one (21) days (if applicable):

Yes No

	Country	Date of Visit
1
2
3
4
5

2. Have you been tested for COVID – 19 within the last (21) days?

Yes No

a. If you answered “Yes” to question two (2) please provide details below:

Test Type	Test Location

Date of Testing

Reason for Testing

3. Have you visited or been in contact with / exposed to individuals testing positive for COVID19 /persons exhibiting any of the symptoms of the virus (21) days?

Yes No

If yes, state particulars

4. Have you been in contact with / exposed to individuals that may have been in contact with individuals testing positive for COVID19 /persons exhibiting any of the symptoms of the virus within the last twenty-one (21) days?

Yes No

If yes, state particulars

5. Are you or any members of your family exhibiting any of the symptoms of the virus? (Tick for applicable symptoms):

Yes No

(Tick applicable symptoms)

Symptom	Yes/No
Fever >100.4F (38C) or Chills
Fatigue
Runny Nose
General feeling of being unwell
Loss of taste or smell
Conjunctivitis

Symptom	Yes/No
Dry cough or Sore throat
Headaches
Muscle aches and pains
Shortness of breath
Diarrhea, Nausea or Vomiting
A rash on skin, or discoloration of fingers or toes.

Have you ever tested positive for COVID-19

Yes No

If Yes, please insert date and fit to work date:
COVID-19 Positive Test Date	Fit to Work Date

6. Vaccination Status

Fully vaccinated Partial vaccination Unvaccinated

Date of 2nd dose:

If fully vaccinated, have you received your booster shot?

Yes No

Date of booster shot:

7 Has your company implemented a plan, or any measures, in response to the SARS-CoV-2 virus / COVID-19?

Yes No

Please provide details:

Upload company plan (if any) *Image or PDF files only
*Reupload file if form had errors

By selecting this checkbox, I declare that the responses contained herein are true and correct and agree to my immediate removal from any of DeNovo’s sites should any of my responses herein be found to be untrue and incorrect. I also hereby consent to DeNovo collecting, processing and storing any of my personal and sensitive data (as defined in the Data Protection Act 2011) provided in this form, for the purposes of determining the level of my exposure to 2019 Novel Coronavirus virus and any further action required to be taken.

Cancel

References;

Government of the Republic of Trinidad and Tobago Ministry of Health
World Health Organisation
IOGP-IPIECA Health Committee statement on COVID-19 testing in the oil and gas industry June 2021