COVID-19 screening questionnaire form template

£ 1

A COVID-19 screening questionnaire should be designed to identify individuals who may have symptoms of COVID-19 or who have been in close contact with someone who has tested positive for COVID-19.

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Time to read / prep / use
5 mins
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Document specs
216 words, 1 page
Date last reviewed icon
Date last reviewed
1 June 2024
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covid-19 screening questionnaire form template

What is this form for?

A COVID-19 screening questionnaire is a set of questions designed to identify individuals who may have symptoms of COVID-19 or who have been in close contact with someone who has tested positive for COVID-19. The questionnaire typically includes questions about symptoms, recent travel, and potential exposure to COVID-19.

COVID-19 screening questionnaires can be used by healthcare facilities, employers, schools, and other organisations to help identify individuals who may need to be tested for COVID-19, self-isolate, or quarantine. The purpose of the questionnaire is to help prevent the spread of COVID-19 by identifying individuals who may be infected and taking appropriate precautions to limit their contact with others.

Depending on the situation, a COVID-19 screening questionnaire may be administered in person, online, or over the phone. It is important to ensure that the questionnaire is designed to collect accurate and relevant information, and that individuals are informed of the importance of answering the questions truthfully and to the best of their knowledge.

Issued by who, to whom
Who should issue this form, and to whom?
The Employer (you) to the Employee
Applicable legal jurisdictions
In which jurisdictions can this form be used?
Great Britain & NI (United Kingdom), Worldwide
  • General Data Protection Regulation (GDPR): Ensures that the collection and processing of personal data through the COVID-19 screening questionnaire comply with data protection principles.

  • Health and Safety at Work Act 1974: Requires employers to assess and manage risks to health and safety, including implementing measures such as COVID-19 screening questionnaires to identify potential risks in the workplace.

  • Equality Act 2010: Requires employers to consider reasonable adjustments and accommodations for employees with disabilities or underlying health conditions when implementing the COVID-19 screening questionnaire.

  • The Control of Substances Hazardous to Health Regulations 2002: Provides a framework for employers to assess and control the risks associated with hazardous substances, including viruses like COVID-19, and implementing screening questionnaires can help identify potential exposure risks.

  • The Health and Safety (Display Screen Equipment) Regulations 1992: Employers should consider the impact of remote work arrangements and implement screening questionnaires to assess the health and safety risks associated with working from home during the pandemic.

  • The Management of Health and Safety at Work Regulations 1999: Employers have a duty to conduct risk assessments and take appropriate measures to protect the health and safety of employees, including implementing COVID-19 screening questionnaires to identify potential risks and implement control measures.

  • The Public Health (Control of Disease) Act 1984: Provides legal powers to public health authorities to control the spread of infectious diseases, and implementing COVID-19 screening questionnaires can help identify and manage potential cases within the workplace.

  • Occupational Health and Safety regulations: Depending on the industry, specific occupational health and safety regulations may require the implementation of COVID-19 screening questionnaires as part of risk management and prevention strategies.

COVID-19 screening questionnaire

  1. Have you experienced any of the following symptoms in the last 14 days? (Check all that apply)
  • Fever or chills

  • Cough

  • Shortness of breath or difficulty breathing

  • Fatigue

  • Muscle or body aches

  • Headache

  • New loss of taste or smell

  • Sore throat

  • Congestion or runny nose

  • Nausea or vomiting

  • Diarrhea

  1. Have you tested positive for COVID-19 in the last 14 days?

  2. Have you been in close contact with someone who has tested positive for COVID-19 in the last 14 days?

  3. Have you been advised by a healthcare professional to self-isolate or quarantine in the last 14 days?

  4. Have you traveled outside of the country in the last 14 days?

  5. Have you been advised by a healthcare professional to self-isolate or quarantine after traveling outside of the country in the last 14 days?

If an individual answers "yes" to any of the questions above, they should be advised to stay home, self-isolate or quarantine as appropriate, and seek medical advice. Depending on your workplace policies, they may also be required to inform their employer or supervisor of their situation.

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