Life! Program RISK SCREENING

Complete Name *

First

Last

Date *

Phone (mobile preferred) *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Please respond to each of the following questions below truthfully and to the best of your knowledge.

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms below? *

• Fever (>38°C or greater) *

• Cough *

• Shortness of breath or difficulty breathing *

• Sore throat *

• Loss of taste and/or smell *

• Chills *

• Head or muscle aches *

• Nausea, vomiting or diarrhea *

In the past 14 days, have you knowingly been in contact with anyone who was experiencing or has since experienced any of the above symptoms since your contact? *

Have you been in contact with a suspected or confirmed COVID-19case? *

In the past 14 days, have you been in a confirmed hotspot within Victoria or interstate? *

In the past 14 days, have you been on a commercial flight, or have you been in contact with anyone who has been on a commercial flight? *

Are you awaiting a COVID-19 test result? *

Are you above 65 years of age? *

Are you of Aboriginal or Torres Strait Islander descent and above 50 years of age? *

Are you currently living with or being treated for a condition that compromises your immunity? *

If you have responded YES to any of these questions, we reserve the right to provide alternative services such as online program delivery, or telephone health coaching.

To reduce the risk of transmission of COVID-19, I agree that it is my responsibility to: .

Adhere to good hand hygiene practices including the use of hand sanitiser. *

Maintain physical distancing of at least 1.5m from other people while participating in the program *

Follow appropriate measures for coughs and sneezes (such as coughing into arm, using tissues, washing hands, and using hand sanitiser) *

Stay home if I am unwell or have been in close contact with a person who has tested positive for COVID-19 or is waiting on a COVID-19 test result *

If a person tests positive for COVID-19 and has been known to attend this education session, contact tracing may be required. Your personal information, including name and contact details, may need to be shared with necessary governing health bodies for the purpose of COVID-19 contact tracing.

I have read the above information and confirm that I will abide by the above:for the purpose of COVID-19 contact tracing.

• I confirm that the responses provided above are true and accurate to the best of my knowledge.

• I consent to my personal information being shared for the purpose of COVID-19 contact tracing.

Todays Date *

Thank you for your cooperation!

Signature

Please respond to each of the following questions below truthfully and to the best of your knowledge.

To reduce the risk of transmission of COVID-19, I agree that it is my responsibility to: .

If a person tests positive for COVID-19 and has been known to attend this education session, contact tracing may be required. Your personal information, including name and contact details, may need to be shared with necessary governing health bodies for the purpose of COVID-19 contact tracing.

I have read the above information and confirm that I will abide by the above:for the purpose of COVID-19 contact tracing.

• I confirm that the responses provided above are true and accurate to the best of my knowledge.

• I consent to my personal information being shared for the purpose of COVID-19 contact tracing.

Thank you for your cooperation!

Contact

Our Programs

Members

Policies

About AB Health & Fitness

Life! Program RISK SCREENING

Please respond to each of the following questions below truthfully and to the best of your knowledge.

To reduce the risk of transmission of COVID-19, I agree that it is my responsibility to: .

If a person tests positive for COVID-19 and has been known to attend this education session, contact tracing may be required. Your personal information, including name and contact details, may need to be shared with necessary governing health bodies for the purpose of COVID-19 contact tracing.

I have read the above information and confirm that I will abide by the above:for the purpose of COVID-19 contact tracing.

• I confirm that the responses provided above are true and accurate to the best of my knowledge.

• I consent to my personal information being shared for the purpose of COVID-19 contact tracing.

Thank you for your cooperation!

Contact

Our Programs

Members

Policies

About AB Health & Fitness

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