Staff daily Covid-19 declaration

Name *

First Name Last Name

Email *

example@example.com

Have you tested positive for COVID-19 in the last 7 days? *

yes no

Are you waiting for a COVID-19 test or the results? *

yes no

Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days? *

yes no

Do you have any of the following symptoms:

New, continuous cough*; High temperature or fever; Loss of, or change in, sense of smell or taste?

* A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If the patient usually has a cough, it may be worse than usual.

If you have answered YES to any of the above, you should not attend the practice. Please inform either Sophie or Graham so that alternative arrangements can be made.

If you have recovered from COVID-19, or completed a period of self-isolation, you are able to attend the practice.

A person is considered to have recovered from COVID-19 infection when they meet all of the following criteria:
• It has been at least 7 days since the onset of the COVID-19 symptoms;
• They no longer have a high temperature.
N.B. A cough may persist for several weeks in some people, even though the coronavirus infection has cleared. The loss of, or change in, sense of smell or taste may also linger. According to the CMO letter (18 May 2020) a person with a persistent cough and/or loss of sense of smell or taste but no other symptoms does not need to continue to self-isolate for more than 7 days.

I hereby declare that the information provided is complete and accurate. I fully understand that any false information can put colleagues and patients at a higher risk of contracting COVID-19 disease. I fully agree to follow all the instructions regarding precautionary steps, ppe and practice protocols.
I am working at the clinic with full knowledge that we are going through a COVID-19 global pandemic.
There is always a risk of contracting this virus when I am working at or visiting a place during this pandemic.
There is a possible risk of getting this virus by working at or visiting any place during this pandemic. I have been fully explained the content of this declaration form in a language that I can understand.
I hereby give my consent for this.

Signature *

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