Western HSC Trust

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?

Yes No

You will need to follow the isolation and testing guidelines relating to your particular situation. Click here for More Information

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

Yes No

You will need to follow the isolation and testing guidelines relating to your particular situation. Click here for More Information

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)?

Yes No

You will need to follow the isolation and testing guidelines relating to your particular situation. Click here for More Information

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

Yes No

You will need to follow the isolation and testing guidelines relating to your particular situation. Click here for More Information

Do you have any of the following symptoms?

High temperature / fever New, continuous cough (not a chronic cough) A loss or alteration to taste or smell

You will need to follow the isolation and testing guidelines relating to your particular situation. Click here for More Information

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You have Completed Covid Self-Certification on 04/01/2026 14:24:38.

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