Annexure B: Self-screening questionnaire
COVID-19 Self Screening Questionnaire - University of Moratuwa
Name
Udara A.G.N.
Student Reg. No
190636M
Home Address
No 36, Wallewala, Hattota Amuna, Matale
District
Matale
NIC Number
991890432V
Contact Number
0765271109
Contact Number (emergency)
1. Did you have any of the following symptoms during the last ONE week?
a) Fever
Yes /No
b) Cough / Cold
Yes /No
c) Sore throat
Yes /No
d) Loss of smell or taste
Yes /No
e) Any other reason necessitating to take medicine
2. Have you been diagnosed as CoViD 19 during last TWO weeks?
3. Have you been quarantined during last ONE month?
Yes /No
Yes /No
Yes /No
4. Have you been tested for CoViD 19 (PCR or Rapid Antigen) during last
ONE month?
5. Have any of your family members or someone you associated with
Yes /No
Yes /No
during last TWO weeks tested POSITIVE for CoViD 19?
6. Have any of your family members or someone you have associated with during
Yes /No
last TWO weeks had fever, cough, cold or sore throat?
7. Have any of your family members or someone you associated with
during last TWO weeks had tested for Covid-19 (PCR or Rapid Antigen)?
8. Have any of your family members or someone you associated with, returned
Yes /No
Yes /No
to Sri Lanka from oversees during last TWO weeks?
9. Have any of your family members or someone you associated with during last
TWO weeks been quarantined?
Yes /No
10. Have you obtained the CoViD 19 Vaccination
Yes /No
Sinopharm
Name of the Vaccine ……………………..………..
Date of the FIRST dose …………………………..
Date of the SECOND dose…………………………
I declare that the above information furnished is true and accurate to the best of my
knowledge. If there is any change to the above after submitting, I will keep the University
informed.
Signature:
Date:
Official Only:
Checked by:
Name:
Signature: