COVID-19 health assessment form

If you answer YES for any of the following questions, you’ll need to speak with the form issuer.

Fill in the date and time the form was completed:

If you have answered ’no’ to these questions but go on to develop any potential symptoms of Covid that last for longer than 1 day, or there be any other changes to your health or circumstances that you think may be relevant, you must notify akt immediately.