Section 1: Personal Details
Section 2: Health - Are you suffering from any of the following?
A new, continuous cough?
A high temperature/Fever?
A loss or change to your sense of smell or taste?
Have you been in contact with anyone that has any of the above symptoms?
Are you pregnant?
Do you care for someone with a health condition that might put them at a greater risk?
Section 3: Travel and Work
Have you entered or returned to the UK from another country in the last 14 days?
If yes, on what date did you enter the UK?
If yes, what country/s have you been to?
If yes, did you pass through another country on your way to the UK?
Have you travelled in the UK?
If yes please specify where : -
If yes please specify when: -
To your knowledge, have you been in contact with anyone that has entered or returned to the UK from abroad in the last 14 days?
Have you worked in the last 14 days?
If yes, Please specify the Company names and locations & Date