COVID-19 Risk Assessment - I Can Jump Puddles

This form is a risk assessment questionnaire for screening purposes to ensure the participant has not been to any COVID-19 exposure sites. In the case that the participant has been to one of these exposure sites this will be flagged and the face-to-face meeting will be cancelled in accordance with SA Health directives.

Details

Participant Name(Required)

NDIS Number(Required)

Practitioner Name(Required)

Date of Meeting(Required)

Time of Meeting(Required)

Address of Meeting(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Screening Questionnaire

Have you or any other resident family members visited a listed exposure site in the last 14 days?(Required)

Yes

Have you or any other resident family members returned from interstate or overseas in the last 14 days?(Required)

Yes

Have you or any other resident family members been in contact with a confirmed case of COVID-19 in the last 14 days?(Required)

Yes

Have you or any other resident family members have a fever or symptoms of a respiratory infection such as cough, sore throat or shortness of breath?(Required)

Yes

Guidelines for Visiting

Can Jump Puddles team members may still visit clients; however, must take extra precautions. These include: • making sure visits are kept short • allowing no more than two visitors, at a time • following best practice hygiene – including washing and sanitising hands before and after visit • making sure visits occur in a spacious room or consider outdoors, where appropriate, to satisfy social distancing guidelines – 4 square metres indoor space per person • ensuring there are no large group visits or gatherings, including social activities or entertainment