COVID-19 Report

• Document No.

• Audit Title

• Investigation conducted on

  Date

• Prepared by

• Location
  Address

COVID-19 Information Report

• Member/Team Member Name

• Date & Time of Incident

  Date

• All clubs visited in the past (2) two weeks

  Select Soho Tower Bridge Marylebone Islington City Canary Warf

  • Soho
  • Tower Bridge
  • Marylebone
  • Islington
  • City
  • Canary Warf

• Areas of club used

• Anyone closer than 2 meters for longer than 15 minutes?

  Yes

  No

• Who?

• Where you wearing PPE during this time?

  Yes

  No

  Does not remember

• Has NHS been contacted and protocols followed in regards to track and trace?

  Yes

  No

• Date of Test?

  Date

• Date of test confirmation?

  Date

• Additional information:

• Report sent to: GM daren.darby@thirdspace.london

  Yes

  No