Staff Screening Kindly complete the below screening form for ALL staff entering the branch Please enable JavaScript in your browser to complete this form.Name *Branch AdminSurname *Branch AdminFCSA Branch *BoskruinBoxburgBryanstonCenturionClearwaterDainfernGlenvistaKyalamiMenlynMidrandMorningsideVictory ParkFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 2nd test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 3rd test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 4th test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 5th test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 6th test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 7th test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 8th test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 9th test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusWould you like to conduct a 10th test/check-in? *YesNoFull Name of staff member *Temperature Reading *Date / Time *DateTimeSignature of Staff Member * Clear Signature By signing you agree that you are not displaying any of the associated COVID-19 Symptoms such as: Headache, Cough, Fever, Shortness of breath, Sore Throat, Fatigue, Loss of smell/taste, Body Aches, Chills, Diarrhea, ConjuctivitusSubmit Screening
