Covid-age Individual Vulnerability Questionnaire

Updated 1 Jun 2020

First name: Surname:

Job role: Date of birth:
Covid Age factor Number of years added/subtracted
Sex: Male No change
Female -8
Ethnicity: Asian or Asian British +4
Black +6
Mixed +5
Other non-white +3
White No change
BMI: Under 30 No change
30-34.9 +4
35-39.9 +5
40+ +10
Covid Age without comorbidity
Are you pregnant? Yes/No If yes, do you want to work
from home or attend work?
Do you have a shielding letter, shielding Yes/No If yes, refer to occupational
condition or vulnerable condition? health to clarify vulnerability
Do you Heart disease Yes/No If yes, refer to occupational
have: Kidney disease health for further
Respiratory disease including assessment
asthma
Liver disease
Neurological problems
Immune therapy or immune
disorder
Diabetes
Covid Age with comorbidities
Vulnerability group selected after discussion Very high Covid Age mid-70s and above
with the worker: High Covid Age 60s to mid-70s
Moderate Covid Age 40s and 50s
Low Covid Age up to low 40s
Decision on role:

Trained and fit tested to use appropriate PPE: Yes/No

Name of Signature of
assessor: assessor:
Date of Signature of
assessment: employee: