COVID-19 Self-Assessment Questionnaire

Are you currently experiencing any of the following symptoms?

High temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
YesNo

New, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)
YesNo

Loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal
YesNo

If you’re currently experiencing any of the above symptoms, or have experienced them in the past 14 days, please inform us immediately and refrain from visiting our premises.

Have you returned from another Country in the last 14 days?
YesNo
If yes, please give details:

Have you been in close contact with anyone who has had a confirmed case of Covid-19?
YesNo
If yes, please give details:

Do you live in the same household as someone who has symptoms of Covid-19, who has been in isolation within the last 14 days?
YesNo
If yes, please give details:

Have you been medically tested and confirmed with a positive case of Covid-19?
YesNo
If yes, please give details:

Statement of Consent and Declaration
I give my consent for information about my health to be shared with relevant staff in order to safeguard the Health & Safety in the Workplace. I declare that the information I have given is true and complete to the best of my knowledge.