Health Declaration

Health Screening Form

- Step 1 of 2

Please input your details below

Name *

First

Last

Company *

Email *

Contact Mobile Phone Number *

Please fill out the below details to the best of your knowledge:

Have you, or anyone in your household or support bubble; (tick any that apply)

Experienced symptoms in the past 10 days such as fever (temperature above 37.8c)
A new continuous cough (continuous = frequent coughing each hour at least 3 times a day)
Loss of sense of smell or taste
Knowingly had contact with someone who has tested COVID-19 positive in the last 10 days
Been instructed to self isolate by NHS111, Contract Tracing contact tracing or your employer
Subject to a local lockdown and travel restrictions based on your residence
Travelled internationally from or through a country or region identified as requiring quarantine within the last 10 days
Awaiting the results of a COVID test

COVID-19 Screening

Before submitting the Medical Screening Questionnaire please confirm; *

I've completed the questionnaire as accurately as possible;
I will take a COVID -19 test in the 24 hrs before arrival to site and provide evidence of a Negative result at check in.

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Signature

Please enter the date below:

Health & Safety Risk Management Software.

Support@do-safety.com