Health Screening Form – Get Me Out The 4 Walls

Please complete this Health Screening Form no later than than 5pm the day before the Meet is due to take place.

The questions on this form are based on the information provided by the NHS.

All information provided is taken in confidence and will be deleted 21 days after the Meet has taken place.

Should you or another member of your household start to develop Coronavirus symptoms within 14 days of attending a GMOTFW meet, please inform Lucinda Terry on admin@getmeout.org.uk

Health Screening Form

Full Name *

Date of Meet *

Location of Meet *

1. Have you, or any member of your household, been in contact with a known infected person or a person who is self-isolating, within the last 14 days? *

Yes

2. Are you, or any member of your household, currently showing any coronavirus symptoms? E.g. New cough, shortness of breath, high temperature or loss of taste or smell? *

Yes

3. Have you, or any member of your household, been advised to self-isolate? *

Yes

If you have answered yes to any of the questions above, unfortunately, you will not be able to attend the Meet.

You will receive a further confirmation email once this Health Screening Form is received. Please do not attend the Meet, until you have received this email.

If you have any questions, please send an email to admin@getmeout.org.uk