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Corona Form Version 7.3

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9 views

Corona Form Version 7.3

Uploaded by

alanogilvie
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
You are on page 1/ 3

ACI TRAINING & CONSULTANCY LTD

Form: Work Health Assessment – Corona Virus


Rev. 7.3

Title: Click or tap here to enter text. Male Female


Surname: Click or tap here to enter text. First Name:
Click or tap here to enter text.
Professional Registration Number: Click or tap here to enter text. Grade and Speciality:
Click or tap here to enter text.
Telephone Number:
Email Address: Click or tap here to enter text. Click or tap here to enter text.
Agency working For: Click or tap here to enter text.
CORONA VIRUS Risk Assessment / Screening
In line with the latest government guidelines there is now no longer a list of affected countries just guidance on what
to do if you develop symptoms.

Please answer all of the following questions

Are you willing to work in wards impacted by COVID – 19 YES NO

Do you have a High temperature YES NO


Do you have a New continuous cough YES NO
Have you in the last 7 days been in immediate contact with anyone proven to have COVID – 19 YES NO
Have you been outside of the UK, returning to the UK in the last 4 weeks (from 25- 02-2020) YES NO
Do you have any underlying health conditions which could affect the work you are going to do YES NO
Are you a recipient of solid organ transplants YES NO
Are you undergoing active chemotherapy or radical radiotherapy for lung cancer YES NO
Do you have cancer of the blood or bone marrow such as leukaemia, lymphoma, or myeloma and YES NO
are at any stage of treatment
Are you having immunotherapy or other continuing antibody treatments for cancer YES NO
Are you having other targeted cancer treatments that can affect the immune system, such as YES NO
protein kinase inhibitors or PARP inhibitors
Have you had bone marrow or stem cell transplantations in the past six months or who are still YES NO
taking immunosuppression drugs
Do you have a severe respiratory condition, including cystic fibrosis, severe asthma, or severe YES NO
chronic obstructive pulmonary disease
Do you have any rare diseases and inborn errors of metabolism that significantly increase the risk YES NO
of infections (such as severe combined immunodeficiency or homozygous sickle cell)
Are you on immunosuppression therapies sufficient to significantly increase the risk of infection YES NO
Are you a pregnant woman with significant heart disease, whether congenital or acquired YES NO
Are you over 70 YES NO
Do you have Diabetes YES NO
Do you have a weakened immune system YES NO

Are you pregnant? YES NO


If yes please provide information on how many weeks below as a separate pregnancy risk assessment may be
required

Weeks? Click or tap here to enter text.

It is your responsibility to make sure that you follow the attached links and comply with the directions therein.

Page 1 of 3
STAFF IN CONFIDENCE WHEN COMPLETE
ACI TRAINING & CONSULTANCY LTD
Form: Work Health Assessment – Corona Virus
Rev. 7.3

What to do if you have symptoms

Stay at home for 7 days if you have either:


 a high temperature
 a new continuous cough
This will help to protect others in your community while you are infectious.

What to do if you do not have symptoms but have been in contact with someone who has.

Stay at home for 14 days.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/874281/
COVID-19_easy_read.pdf

Do not go to a GP surgery, pharmacy or hospital.


You do not need to contact NHS 111 to tell them you’re staying at home.
We will not be testing people who are self-isolating with mild symptoms.
COVID-19: stay at home guidance
Number of Cases identified in England
https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public#risk-level
Confirmed cases in each local authority and NHS region are published by Public Health England (PHE).
Risk level
The risk to the UK has been raised to high.
Recent government action
The government published its coronavirus action plan on 3 March 2020.
On 10 February 2020, the Secretary of State for Health and Social Care, Matt Hancock, announced strengthened
legal powers to protect public health.
The Health Protection (Coronavirus) Regulations 2020 have been put in place to reduce the risk of further human-to-
human transmission in this country by keeping individuals in isolation where public health professionals believe
there is a reasonable risk an individual may have the virus.
Further information
Coronavirus (COVID-19): UK government response
Travel advice: coronavirus (COVID-19)
Coronavirus (COVID-19): guidance for health professionals and other organisations

This is a highly precautionary measure to limit the potential spread of infection.

In addition to the above you are required to inform your agency Immediately (Your Recruitment Consultant or
Compliance Consultant) if you have been or come in to contact with a known case of COVID-19

https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public updated at 2PM each day.

DECLARATION: I Confirm that I have received, read and understood the above information and
that the answers I have provided are correct at the time of completing this form.

Signature: _ Click or tap here to enter text. Date: _ Click or tap to enter a date.

(If this is being sent from your personal email address then please just put you name above)
Page 2 of 3
STAFF IN CONFIDENCE WHEN COMPLETE
ACI TRAINING & CONSULTANCY LTD
Form: Work Health Assessment – Corona Virus
Rev. 7.3

ACI OH staff confirm that only electronically typed forms that have come direct from the candidates
own email address are sanctioned

FOR COMPLETION BY ACI ONLY

Date Received: _ Click or tap to enter a date. __ Signature:__

Registered Nurse – Diploma (HE) Registered Nurse – Diploma (HE) Registered Nurse – Occupational
in Occupational Health (Nurses) in Occupational Health (Nurses) Health Advisor

K Lewis E Chinn N Dalziel


Date Reviewed: _ Click or tap to enter a date. __ Signature:____

Registered Nurse – Diploma (HE) Registered Nurse – Diploma (HE) Registered Nurse – Occupational
in Occupational Health (Nurses) in Occupational Health (Nurses) Health Advisor

K Lewis E Chinn N Dalziel


Date Sanctioned: _ Click or tap to enter a date. _ Signature

Registered Nurse – Diploma (HE) Registered Nurse – Diploma (HE) Registered Nurse – Occupational
in Occupational Health (Nurses) in Occupational Health (Nurses) Health Advisor

K Lewis E Chinn N Dalziel


Pregnant: YES NO.

If yes has Pregnancy risk assessment been completed? YES NO Date __


Click or tap to enter a date.

Other Comments

Click or tap here to enter text.

Page 3 of 3
STAFF IN CONFIDENCE WHEN COMPLETE

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