INFECTION PREVENTION AND CONTROL AGREEMENT
UNIVERSITY OF GHANA COVID-19 SCREENING QUESTIONNAIRE
The safety of our students and faculty is our overriding priority. As the coronavirus (COVID-19) pandemic
continues, we are monitoring the situation closely and following guidance from the Ghana Health Service and
University of Ghana health authorities. In order to prevent the spread of the coronavirus and reduce the
potential risk of exposure to our students and faculty, we are asking everyone to complete and submit this
questionnaire prior to entering any of the UG campuses. Please be informed that your responses will be
reviewed and you will be contacted if you are considered to be at risk of contracting COVID-19.
Please respond to each of the following questions truthfully and to the best of your ability. Your
participation is important to help us take precautionary measures to protect you and our other employees.
Name : SUGLO SOLOMON
Student ID: 22010167
Hall of Residence:
Academic Programme: PHD NURSING
Tel: 0508658201
Email: N/A
Representations
Are you currently experiencing, or have you experienced in the past 14 days, any of the
following symptoms?
a. Major symptoms
1
Yes []
No [✓]
Fever (37.8° C or greater as measured by a clinical thermometer)
Yes []
No [✓]
Shortness of breath or difficulty breathing
Yes []
No [✓]
Loss of smell
Yes []
No [✓]
Loss of taste
Yes []
No [✓]
Sore throat
a. Minor symptoms
Yes []
No [✓]
Cough
Yes []
No [✓]
Chills
Yes [✓]
Yes []
No []
No [✓]
Head or muscle ache
Nausea, diarrhoea, vomiting
In the past 14 days, have you been in close proximity to anyone who was experiencing any of
2
the above symptoms or has experienced any of the above symptoms since your contact?
Yes []
No [✓]
In the past 14 days, have you been in close proximity to anyone who has tested positive for
3
COVID-19?
Yes []
No [✓]
In the past 30 days, have you tested for COVID-19? Yes/No
4
Yes []
No [✓]
Is there any reason why you think you are at an increased risk of contracting COVID-19?
5
Yes []
No [✓]
7. In the last 14 days, have you arrived in Ghana from abroad?
6
Yes []
No [✓]
Certification
I hereby certify that the responses provided above are true and accurate to the best of my knowledge
Signature/Initials: SS
Date: October 10, 2023
Note: The information collected on this form will be used to determine only whether you may be infected with
COVID-19. The information on this form will be maintained as confidential. Any questions should be directed
to the University of Ghana Hospital COVID-19 hotline