Main Menu Cvd19 Screening Form Categorize Ref no. * Quick Screening Quick Screening Register Screening Type Visitors Manual Entry Student nr Staff nr Student Name Staff Name Personal Details Title MrMissMrs First Name * Surname * ID Number Gender * –Select–MaleFemaleNon-binary Race –Select–AfricanWhiteIndianAsianColored Date of birth Contact number * Street Address (where you are currently residing) * Type of dwelling (e.g. house, flat etc) Dwelling size 0-2 bedrooms 3–5 bedrooms 6+ bedrooms Demographic Information Province Eastern CapeFree StateGautengKznLimpopoMpumalangaNorth WestNorthern CapeuncategorizedWestern Cape Occupation Specify occupation * Scholar Office worker Mine worker Taxi / Bus/ Truck driver/ conductor Healthcare worker Unemployed Other Physical Activity Temperature Reading Temperature Alert Temp Alert Medical History Specify Medical History Asthma COAD – Chronic Obstructive Airway Disease Diabetes Hypertension TB Other Chronic Disease Med History Alert Med history Alert Travel Specify travel history Travel outside RSA since 1 February 2020 Travel outside FS since 1st March 2020 Travel outside KZN 1st March 2020 Travel outside GP since 1st March 2020 Travel outside NW since 1st March 2020 Travel outside EC since 1st March 2020 COVID-19 contact/ exposure Travel alert Travel alert Recent Medical Care Recent medical care Clinic visit GP visit Hospitalisation Signs And Symptoms Signs and symptoms Fever ( high temperature) Cough Sore throat Shortness of breath Loss of taste (ageusia) Myalgia/general weakness Loss of the sense of smell (anosmia) Signs/Symptoms Alert Signs Alert Take a picture as a signature (Verification) Drop a file here or click to upload Choose File Maximum file size: 268.44MB Alert Counts NOTE: Enlight Business Solutions will not use or save the data submitted on this form. The information collected will be sent to the management of the Organization doing the Screening. Submit button note Please Note: You need to login to be able to submit this form. If you are human, leave this field blank. Submit