CORONAVIRUS Questionnaire

Enter Screening No.

Do you or any member of your household / family have a confirmed diagnosis of Covid-19 within the last 10 days?

Have you been a close contact of a positive case within the past 10 days?

Are you or any member of your family / household waiting for a test result? (not applicable to those who are undertaking asymptomatic testing as part of a national testing programme, unless there is a current Covid -19 outbreak there)?

Have you traveled to any country outside NI in the previous 10 days?

Do you have any of the following symptoms?

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