Covid-19 - Close Contact Confirmation Questionnaire

Date of questionnaire: ___________________________

Name of confirm case:___________________________________
Date of confirm case:____________________________________
Dept: ________________ Section: _________________
Contact since:________________ till _______________
Questionnaire by: _______________________________

No. Description Yes No

a) Working within 6 ft & spend 15 mins with Covid 19 infected person
Wearing or Not Wearing face mask correctly; covering nose & mouth-
b)
referring to (a) / while with Covid 19 infected person
c) Physical contact with Covid 19 infected person
d) Shared same mode of transportation; to or from work
e) Lunch together; same table, enclosed room or area…
*I declare the above feedback are true as on questionnaire date

Sign:
Name:

Covid-19 - Close Contact Confirmation Questionnaire

Date of questionnaire: ___________________________

Name of confirm case:___________________________________
Date of confirm case:____________________________________
Dept: ________________ Section: _________________
Contact since:________________ till _______________
Questionnaire by: _______________________________

No. Description Yes No

a) Working within 1 meter & spend 15 mins with confirm case
b) Not Wearing face mask correctly; covering nose & mouth-referring to (a)
c) Physical contact with confirm case
d) Shared same mode of transportation; to or from work
e) Lunch together
*I declare the above feedback are true as on questionnaire date

Sign:
Name: