VERSUS @ TheFourth
COVID-19 CONTACT TRACING & DECLARATION: SEPTEMBER 2021

Question Title

* 1. You are important to us and in order to limit the spread of covid-19 we would appreciate it if you could disclose the following information. All information will be held in confidence.

Name

Company

Company Phone Number

ID Number

Email Address

Phone Number

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* 2. DO YOU HAVE ANY OF THE FOLLOWING FLU LIKE SYMPTOMS?

	Yes	No
Fever (> 37,5°C) or a history of fever or chills	Fever (> 37,5°C) or a history of fever or chills Yes	Fever (> 37,5°C) or a history of fever or chills No
Cough (sudden onset)	Cough (sudden onset) Yes	Cough (sudden onset) No
Sore throat	Sore throat Yes	Sore throat No
Difficulty breathing	Difficulty breathing Yes	Difficulty breathing No
Loss of smell and/or loss of taste	Loss of smell and/or loss of taste Yes	Loss of smell and/or loss of taste No
Body aches	Body aches Yes	Body aches No
Nausea, vomiting or diarrhea	Nausea, vomiting or diarrhea Yes	Nausea, vomiting or diarrhea No
Fatigue and/or Weakness	Fatigue and/or Weakness Yes	Fatigue and/or Weakness No

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* 3. AND IN THE LAST 14 DAYS, IN YOUR COMMUNITY, WERE YOU IN CLOSE CONTACT OR LIVING WITH ANY OF THE FOLLOWING:

	Yes	No
A person with flu like symptoms	A person with flu like symptoms Yes	A person with flu like symptoms No
A confirmed COVID-19 person or a person under investigation for COVID-19	A confirmed COVID-19 person or a person under investigation for COVID-19 Yes	A confirmed COVID-19 person or a person under investigation for COVID-19 No

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* 4. CLOSE CONTACT MEANS YOU WERE FACE-TO-FACE (LESS THAN 1M) WITH THE PERSON / OR YOU WERE IN A CLOSED SPACE (CAR, TAXI OR HOUSE) WITH THE PERSON FOR AT LEAST 15MIN.

	Yes	No
In the last 14 days, have you been admitted with severe pneumonia?	In the last 14 days, have you been admitted with severe pneumonia? Yes	In the last 14 days, have you been admitted with severe pneumonia? No
In the last 14 days, have you worked in, or attended a health care facility where COVID-19 patients are treated.	In the last 14 days, have you worked in, or attended a health care facility where COVID-19 patients are treated. Yes	In the last 14 days, have you worked in, or attended a health care facility where COVID-19 patients are treated. No

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* 5. HAVE YOU TRAVELLED IN THE LAST 21 DAYS? IF SO, WHERE TO?

Yes

No

If yes, to which country have your travelled?

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* 6. I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. I further undertake to inform Reed Exhibitions should I be diagnosed with COVID-19 within the next 14 days so as to facilitate contact tracing.

Yes

No