Individual Attendee COVID-19 Risk Assessment Covid-19 Individual Risk Assessment If you answer yes to any questions from 8 to 11 or 14 to 17 you must isolate and test for COVID-19 Full Name* Group *(THANET) Peer Support Group (Thursday)(THANET) Creative Group (Tuesday)(THANET) Activity Group (Tuesday)(CANTERBURY) Depression Group (Monday)(CANTERBURY) BPD Group (Tuesday)(CANTERBURY) Creative Group (Tuesday)(SHATTERLING) On the Farm (Thursday)(FAVERSHAM) Allotment (Fridays)(HERNE BAY) Peer Support Group (Tuesday)(HERNE BAY) Peer Support Group (Thursday)(DOVER) Depression Group (Monday)(DOVER) Creative Art (Tuesday)(DOVER) IT Group (Thursday)(DOVER) Cooking Group (Friday)(DOVER) Activity Group (Monday)(SHEPWAY) Walking Group (Wednesday) Today's Date (not the date of the group)* Following assessment are you happy for a socially distanced (Current government guidance on safe distance) face to face meeting to be conducted?*YesNo Vulnerability to COVID-191- (Tick if YES) Have you or anyone in your household received a letter from the Government/NHS to continue to shield?2- (Tick if YES) Do you have any new underlying health conditions that we need to be aware of (which would deem you moderately or extremely vulnerable to COVID-19)? 3- (Tick if YES) Have you been discharged from hospital in the last 21 days?4- (Tick if YES) Have you or anyone in your household been in contact with anyone who has displayed symptoms of COVID-19 in the last 21 days? 5- (Tick if YES) If you have said YES to question 4 but have isolated for 10 days and received a NEGATIVE lateral flow test the day before the group please tick this box Symptoms of COVID-196- (Tick if YES) Have you been tested for COVID19 in the last 21 days due to COVID symptoms?7- (Tick if YES) If tested was the result POSITIVE8- (Tick if YES) In the last 21 days have you had a high temperature, been hot to touch on your chest or your back?9- (Tick if YES) In the last 21 days have you had a new and continuous cough that has lasted for more than an hour? 10- (Tick if YES) In the last 21 days have you had a new and continuous cough that has occurred 3 or more times over 24 hours?11- (Tick if YES) If you usually have a cough has this worsened in the last 21 days? About Your Household 12- (Tick if YES) Has anyone in your household been tested for COVID19 in the last 21 days?13- (Tick if YES) If tested was the result POSITIVE14- (Tick if YES) In the last 21 days has anyone in your household had a high temperature, been hot to touch on their chest or their back?15- (Tick if YES) In the last 21 days has anyone in your household had a new and continuous cough that has lasted for more than an hour? 16- (Tick if YES) In the last 21 days has anyone in your household had a new and continuous cough that has occurred 3 or more times over 24 hours?17- (Tick if YES) If they usually have a cough has this worsened in the last 21 days?SubmitReset
