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COVID-19 Return To Work Form

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7 views

COVID-19 Return To Work Form

Uploaded by

nirmaldalvkot
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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COVID-19 Return to Work Form

To help prevent the spread of COVID-19 in the workplace, every individual must complete
and sign this form before returning to work. While reviewing this form, management may try
to contact you and ask you not to return to work immediately and will discuss a suitable
future date for your return. N.B. every question must be answered

Employee Name: Manager Name:

Workplace Address:

Questions Yes No

1. Do you have symptoms for cough, cold, high temperature, sore


throat, runny nose, breathlessness, flu like symptoms, or loss or
change to your sense of taste or smell now or in the past 14 days?

2. Have you been diagnosed with confirmed or suspected COVID-19


infection in the last 14 days?

3. Are you a close contact of a person who is a confirmed or suspected


case of COVID-19 in the past 14 days (i.e. less than 2 meters for more
than 15 Minutes altogether in 1 day)?

4. Have you been advised by a doctor to self-isolate at this time?

5. Have you been advised by a doctor to cocoon at this time?

6. Please provide details* below of any other circumstances relating to


COVID-19, not included in the above, which may need to be considered
to allow your safe return to work. Further information on people at
higher risk from Coronavirus can be accessed here.

Additional Information:

* If you are not sure whether or not you are in an at-risk category, please check the link
in Question 6. If your situation is changed after completing and submitting this form,
please tell the management.

Print Name: Date:

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