Due to current coronavirus disease (COVID-19) pandemic, we require all employees to complete a self declaration and reporting form.
Are you in highest risk group* from coronavirus (clinically extremely vulnerable)?
If Yes, you have been identified as having serious underlying medical conditions anfd therefore should be following government shielding measures for a minimum of 12 weeks
Yes
No
Do you live with someone in the highest risk group from coronavirus (clinically extremely vulnerable)?
If Yes, you live with someone who has been identified as clinically extremely vulnerable and who may be currently shielding and reliant on your help. Whilst this does not prevent you from working it may be that your employer may want to discuss your situation to see if more controls are required.
Do you have a condition that may put you at increased risk from coronavirus (clinically extremely vulnerable)?
If Yes, you may have a condition that is listed as moderate risk by the UK government. Whilst this does not prevent you from working it may be that your employer may want to discuss your situation to see if more controls are required.
Have You experienced any of the recognised symptoms of COVID-19 within the last 7 Days?
This means feel hot to touch on your chest or back
This means coughing for longer than an hour or three or more coughing episodes in 24 hours
This means you have noticed you cannot smell or taste anything, or things small or taste different to normal
Has anyone you live with had symptoms of COVID -19 in last 14 days ?
I will inform my employer immediately if I experience any symptoms of COVID -19.
I will inform my employer immediately of any significant changes to information of the above
