ACROSS Te Kotahitanga o te Wairua requests that all clients attending appointments at our premises or support groups; or staff visiting you in your home or visitors to ACROSS offices complete this questionnaire.  ACROSS is seeking to ensure that both clients and staff are in a safe environment.  This is a short questionnaire and will only take about 2 minutes to complete.  We thank you for your cooperation.

WHO SHOULD COMPLETE THIS FORM

This form should be completed by any person over 16 years of age.  If there are children or youth under the age of 16 years that are included in the same session or service as the parent or guardian and they reside with them then this form can be used for all family members.

However, If the person is under 16 years of age and they do not reside with the adult receiving the service but is with them at the time or the service is only for the child or youth under 16 years of age then a parent or guardian must complete the form separately on their behalf. 

If you require further information please call ACROSS on 0800 227 677.  

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* 2. Your Name

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* 3. Please provide your contact information

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* 4. ACROSS Staff Member Name you are meeting with

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* 5. Are you the only person in direct contact with the ACROSS staff member

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* 6. If you answered NO can you please list the names of the persons that will have contact with the ACROSS Staff Member.

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* 7. Please provide Date and Time for your appointment with ACROSS

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Time

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* 8. Do you or any family member living with you have any vulnerable health conditions that could be severely affected by COVID 19 - for example respiratory disease or low immunse system?

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* 9. If you answered yes to this question could you please outline the vulnerable condition.  We also request that you contact the ACROSS staff member to determine whether it is safe for you visit our offices or our staff to visit you at home.

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* 10. Have you been exposed to any person who has been diagnosed with COVID 19 in the last 14 days?

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* 11. Have you travelled overseas or been in contact with another person who has returned from overseas in the last 14 days?

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* 12. Have you been in self isolation in the last 14 days due to the potential exposure of COVID 19 

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* 13. Do you have any of the following symptoms?

Thank you for your time to answer these questions.  This helps us to ensure we keep you safe and our workplace safe.  If you have any questions please do not hesitate to contact us on 06 356 7486 or 0800 227 677
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