COVID-19 Declaration Form

COVID-19 DECLARATION FORM

Date *

Name *

First

Last

Email *

Telephone *

Company Name *

Site Address *

Purpose of visit *

Do you, or anyone at your workplace, have symptoms of COVID-19 (e.g. cough, fever, loss of smell/ taste)? *

Have you, or anyone at your workplace, been in contact with a COVID-19 patient in the last 14 days? *

Have you, or anyone at your workplace, been to any countries where quarantine restrictions apply on return in the last 14 days?

Name