Coronavirus Self Declaration Form
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name
First Name
Last Name
Have you travelled outside of the UK in the past 14 days?
Yes
No
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
Yes
No
Other
Your relationship with the people and your last contact date with them
Please state whether you've experienced/are experiencing the following
Rows
Yes
No
Fever
Cough
Shortness of Breath
Persistent Pain in the Chest
Are you in the high risk category ( clinically extremely vulnerable ) as defined by the uk government?
Yes
No
Are you in the moderate risk category ( clinically extremely vulnerable ) as defined by the uk government?
Yes
No
I acknowledge that the information I've given is accurate and complete.
Date
-
Month
-
Day
Year
Date
Signature
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