Risk Assessment

Individual Risk Assessment Form

Good day Sir/Ma. This tool is designed to assess your risk for COVID 19. Kindly fill in correct information. Thank you.

Basic Information

Surname

Firstname

Othernames

Initial

Gender:

Male

Female

Phone Number

Email

Age (as at last birthday):

Marrital Status

Detailed Home Address

Staff Category

UI Faculty/Institute/Department/Unit

Matric Number (if you are a student)

Do you Reside in Campus?

Part A: Exposure Related Information

S/N	QUESTIONS	RESPONSE
1	Do you have a friend/relative/neighbor with any of the following symptoms in the last two weeks?
	a. Fever	Yes No
	b. Persistentvc Cough	Yes No
	c. Runny nose or sore throat	Yes No
	d. Body aches	Yes No
	e. Abdominal symptoms (such as diarrhea, vomiting, abdominal pain, loss of appetite)	Yes No
	f. Shortness of breath	Yes No
	g. Recent loss of smell	Yes No
	h. Recent loss of taste	Yes No
2	Have you had any of the following symptoms in the last two weeks?
	a. Fever	Yes No
	b. Persistent Cough	Yes No
	c. Runny nose or sore throat	Yes No
	d. Recent Body aches	Yes No
	e. Abdominal symptoms (such as diarrhea, vomiting, abdominal pain, loss of appetite)	Yes No
	f. Shortness of breath	Yes No
	g. Recent loss of smell	Yes No
	h. Recent loss of taste	Yes No
3	Did you take medications for malaria in the last two weeks?	Yes No
4	Have you had contact with or provided care for a confirmed case of COVID-19 in the last two weeks?	Yes No
5	Have you been tested for COVID-19 within the last 4 weeks? If Yes:	Yes No

Part B: Personal Vulnerability Assessment

There is a certain risk that comes with working in an environment that is considered safe and suitable for learning and work within the reality of the constant threat of COVID-19. An assessment of the vulnerability would help in making decisions about job placements, time gated exposure during learning, individual�s learning options and priorities for prevention and treatment.

	MEDICAL CONDITION	RESPONSE
	If female, are you pregnant?	Yes No
	Gestational age in weeks:
	Hypertension	Yes No
	Cardiovascular disease	Yes No
	Diabetes mellitus	Yes No
	Chronic Kidney Disease	Yes No
	Asthma	Yes No
	Overweight/Obesity	Yes No
	Weakened immunity from conditions like cancer, steroid use or HIV and AIDS	Yes No
	Sickle cell disease	Yes No
	Others specify