COVID-19 SSP Form

COVID-19 SSP Form
Name

First NameLast Name
Required Contact Phone Number
Managers Name
Self Isolating Information
State reason for Self Isolating*
Start Date*

DayMonthYear
Date
Expected End Date*

DayMonthYear
Date
Expected date of return*

DayMonthYear
Date
YesNo
If Yes, please state employee's names that you have been indirect contact with who may now be at risk ( Please note this information will be treated with extreme sensitivity )*
Updated Employee Risk Status
Personal Risk
YesNo
If Yes please give details including reason for risk*
Indirect Risk
YesNo
If Yes please give details including who's at risk and reason why*
Carer's Risk
YesNo
If Yes Please give details of Who is at risk and Why they are at risk and if they live with you or not. State also how much care are you required to provide*
Home-schooling
YesNo
If Yes, state how many children and at what age and if they have additional requirements*
Signed*

Clear
Should be Empty: