COVID-19 Workplace Checklist

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1. First Step

Coronavirus Covid-19 Medical Declaration Form
To help prevent the spread of Covid-19 in the workplace, every employee must complete and sign this form before returning to the workplace. On review of this form, management may contact you to discuss your return to work, or any necessary delay in returning as a result of the answers provided below.

Personal Details

Full Name

Role

Fit for Work and Medical Questionnaire

Are you experiencing any flu like symptoms (e.g fever, headaches, body aches, cough, difficulty breathing)?

Check the NHS website if you think you have Covid 19 symptoms

Yes	No

Have you or anyone in your household been infected by Covid 19?

Yes	No

Have you or anyone in your household been self-isolating, or in quarantine, during the last 14 days due to Covid 19 symptoms?

Yes	No

Have you been advised by a Doctor to self-isolate at this time?

Yes	No

Do you have any clinical vulnerabilities?
Please read the link below and tick yes if anything applies to you.
https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

Yes	No

Are you living with anyone who is deemed clinically vulnerable?

Yes	No

Do you have 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?

Yes	No

If yes, please provide details:

If you are unsure of any answers, please contact the operations manager in charge

If your situation changes after you complete and submit this form, please inform the operations manager in charge immediately

I confirm that I have received and understood the Company Risk Assessment and Procedures document and the toolbox talk for Covid-19 for my workplace.

Yes	Yes

Risk Assessment and Procedures

Yes	No

Toolbox Talk

Yes	No

I confirm that I have completed this form accurately, and to the best of my knowledge at the time of submitting.

Employee Name_

Employee Signature__

Employer Name_

Employer Role__

Employer Signature__