TE COVID-19 Risk Assessment

• Conducted on

  Date

• Prepared by

• Name

• Department / Store

• Job Role

• Location
  Address

Personal Health & Hygiene

• Do you have any flu symptoms such as headaches, running nose, sore throat, cough or fever?

  Yes

  No

• Has anyone in your home travelled overseas in the past two weeks?

  Yes

  No

• Do you have hand sanitizer and hand soap on hand?

  Yes

  No

• Have you been in contact with anyone currently carrying COVI-19

  Yes

  No

• Is anyone else in your household self isolating?

  Yes

  No

• Have you been in contact with anyone currently self isolating?

  Yes

  No

Underlying Conditions

• Are you 70 or over?

  Yes

  No

• Do you suffer from any of the following?

  Select Recent organ transplant Cancer and undergoing cancer treatment Cancer of the blood or bone marrow Severe asthma Cystic Fibrosis Severe kidney disease (on dialysis) None

  • Recent organ transplant
  • Cancer and undergoing cancer treatment
  • Cancer of the blood or bone marrow
  • Severe asthma
  • Cystic Fibrosis
  • Severe kidney disease (on dialysis)
  • None

• If any of the above is selected, then person should self isolate.

• Are you pregnant?

  Yes

  No

• Do you suffer from any of the following?

  Select Asthma COPD Emphysema Bronchitis Chronic Heart disease / Heart Failure Chronic Kidney disease Chronic Liver disease Parkinsons Disease Motor neurone disease MS Cerebral Palsy Diabetes Sickle cell disease Removed Spleen Weakened immune system from HIV or AIDS Weakened immune system from steroids Weakened immune system from Chemotherapy Overweight (BMI of over 40) Other None

  • Asthma
  • COPD
  • Emphysema
  • Bronchitis
  • Chronic Heart disease / Heart Failure
  • Chronic Kidney disease
  • Chronic Liver disease
  • Parkinsons Disease
  • Motor neurone disease
  • MS
  • Cerebral Palsy
  • Diabetes
  • Sickle cell disease
  • Removed Spleen
  • Weakened immune system from HIV or AIDS
  • Weakened immune system from steroids
  • Weakened immune system from Chemotherapy
  • Overweight (BMI of over 40)
  • Other
  • None

• Please write in here any other condition that may be relevant?

• If any of the above have been selected, then social distancing is recommended

• 

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