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    COVID-19 (Coronavirus) Exposure Questionnaire

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    adi
    The document is a COVID-19 exposure questionnaire that asks an applicant a series of questions about their potential exposure to and symptoms of COVID-19. It inquires about close contact with infected individuals, quarantine history, testing history and results, recent symptoms, travel history for the past 14 days and future 30 days, and current health status. The applicant must sign declaring their answers are true and complete.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    COVID-19 (Coronavirus) Exposure Questionnaire

    Uploaded by

    adi
    34 views2 pages
    The document is a COVID-19 exposure questionnaire that asks an applicant a series of questions about their potential exposure to and symptoms of COVID-19. It inquires about close contact with infected individuals, quarantine history, testing history and results, recent symptoms, travel history for the past 14 days and future 30 days, and current health status. The applicant must sign declaring their answers are true and complete.

    Original Description:

    Original Title

    COVID-19_Questionnaire_-_UPDATED_March_19_2020.pdf

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    The document is a COVID-19 exposure questionnaire that asks an applicant a series of questions about their potential exposure to and symptoms of COVID-19. It inquires about close contact with infected individuals, quarantine history, testing history and results, recent symptoms, travel history for the past 14 days and future 30 days, and current health status. The applicant must sign declaring their answers are true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    34 views2 pages

    COVID-19 (Coronavirus) Exposure Questionnaire

    Uploaded by

    adi
    The document is a COVID-19 exposure questionnaire that asks an applicant a series of questions about their potential exposure to and symptoms of COVID-19. It inquires about close contact with infected individuals, quarantine history, testing history and results, recent symptoms, travel history for the past 14 days and future 30 days, and current health status. The applicant must sign declaring their answers are true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    COVID-19 (Coronavirus) Exposure Questionnaire

    Applicant’s Name Application Number:

    Please answer the following questions with as much detail as possible:

    1. Are you, or have you been in close contact with anyone who has been quarantined or who has been
    diagnosed with novel coronavirus (SARS-CoV-2/COVID-19) ? If yes, please provide details.
    Yes No

    2. Have you ever been quarantined due to a possible exposure to novel coronavirus (SARS-CoV-
    2/COVID-19)? If yes, please provide dates and locations.
    Yes No

    3. Have you been advised to be tested to rule in, or rule out, a diagnosis of novel coronavirus (SARS-
    CoV-2/COVID-19)? Or, are you awaiting the result of a test which has already been submitted for the
    novel coronavirus (SARS-CoV-2/COVID-19)?
    Yes No

    4. Have you ever tested positive for the novel coronavirus (SARS-CoV-2/COVID-19)? If yes, provide the
    date of positive diagnosis.
    Yes No

    5. Have you experienced any of the following symptoms within the last 14 days?
    • Any fever
    • Cough
    • Shortness of breath
    • Malaise (flu-like tiredness)
    • Rhinorrhea (mucus discharge from the nose)
    • Sore throat
    • Gastro-intestinal symptoms such as nausea, vomiting and/or diarrhea

    If yes, to any of these, please indicate which and provide full information.

    6. Travel Declaration
    a. Please provide your travel patterns over the past 14 days:

    COUNTRY CITY DATE ARRIVED DATE DEPARTED

    b. Please detail your intended future travel plans for the next 30 days:

    COUNTRY CITY DATE ARRIVAL INTENDED DURATION

    7. Are you currently in good health?


    Yes No

    Declaration
    I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld
    any material information that may influence the assessment or acceptance of this application.

    I agree that this form will constitute part of my application for insurance(s) and that failure to disclose any
    material fact known to me may invalidate my insurance(s).

    Signed at on this day of ,

    Applicant Signature

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