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
Name
Date
2021-12-08
Tel. Contant Number
Email
Department
DeNovo Facility

PERSONAL INFORMATION
Name
Date of Birth
Gender
Tel. Contact Number
Place of Residence (City/Town and Country)
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):
Country Date of Visit
1
2
3
4
5
2. Have you been tested for COVID – 19 within the last (21) days?
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?
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?
5. Are you or any members of your family exhibiting any of the symptoms of the virus? (Tick for applicable symptoms):
(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
If Yes, please insert date and fit to work date:
COVID-19 Positive Test Date Fit to Work Date
6. Vaccination Status
7 Has your company implemented a plan, or any measures, in response to the SARS-CoV-2 virus / COVID-19?
*Image or PDF files only
*Reupload file if form had errors

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