COVID-19 Risk Assessment

This form is a risk assessment questionnaire for screening purposes to ensure the participant has not tested positive to COVID-19 or been directed to isolate by SA Health. In the case that the participant has COVID-19 or been directed to isolate this will be flagged and the face-to-face meeting will be cancelled in accordance with SA Health directives.


DD slash MM slash YYYY
Time of Meeting(Required)
Address of Meeting(Required)

Screening Questionnaire

Is anyone in your household currently experiencing any COVID-19 symptoms (such as Fever, Sore throat, Cough, or loss of taste or smell) and /or waiting for test results?(Required)
Do you or a household member have COVID or have been directed to self isolate by SA Health in the last 14 days?(Required)
In the last 10 days, have you or a household member been identified as a 'close contact' of someone who currently has COVID-19?(Required)

Guidelines for Visiting

I 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