Return to work

To be completed by all clinical staff and instructors

COVID-19 Fit for Work Questionnaire

Personal Details

Screening Questions

Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose? *
Have you returned to UK from outside the country in the past 14 days? *
In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment, did you have close contact with someone who has a probable or confirmed case of COVID19? *
In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment, did you have close contact with a person who had acute respiratory illness that started within 14 days of their close contact to someone with a probable or confirmed case of COVID-19? *
In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment, did you have close contact with a person who had acute respiratory illness who returned from travel outside of UK in the 14 days before they became sick? *
I confirm I am aware of how to don and doff PPE, how to observe social distancing where appropriate and feel confident in my ability to minimise the spread of COVID-19 and adhere to all published guidelines and tops:health risk assessment procedures *
I can confirm I will follow tops:health policies and procedures in relation to COVID-19, including documentation, use of PPE, cleaning, adhering to social distancing, communication with clients and general team working to provide a consistently safe and professional environment *