Covid-19 Return to Work

COVID-19 Contractor Return to Work Form
To help prevent the spread of COVID-19 in the workplace, every contractor must complete and sign this form before returning to work for their clients. On review of the form, a client may not be happy to have you return to their premises immediately, and instead may suggest a suitable future date. N.B. Every question must be answered.

1. Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?
yesno
2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
yesno
3. Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2 metres for more than 15 minutes cumulative in 1 day)?
yesno

4. Have you been advised by a doctor to self-isolate at this time?
yesno

5. Have you been advised by a doctor to cocoon at this time?
yesno

6. Please provide details below of 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. Further information on people at higher risk from Coronavirus can be accessed here.
yesno

Date*

Your Name*

*if you are unsure whether or not you are in an at-risk category, please check the information at the link in Question 6.
** If your situation changes after you complete and submit this form, please inform Aboutime.

Please Sign here