COVID-19 Return To Work Form

1st Floor, Chamber Buildings,
North Street, Swords, Co. Dublin, Ireland
Tel: +353 (1) 8021118 FAX: +353 (1) 8021126
Email: info@fingalhomecare.ie
Return to Work Declaration Form
In line with the Governments, Return to Work Safely Protocol, the Company requires that all employees complete this form prior to their return to the workplace. This form should be returned as soon as possible however, no later than 3 days prior to your return to work.

The company is collecting this sensitive personal data for the purposes of maintaining safety within the workplace in light of the COVID-19 pandemic. The legal basis for collecting this data is based on vital interests and maintaining occupational health and will be held securely in line with our retention policy. This form should be returned to info@fingalhomecare.ie.
Please select one:*
Please select your position. Ex: Care Assistant, Care Supervisor etc..
Please select your Area:
- Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, or flu like symptoms now or in the past 14 days?*
  
  YESNO
- Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?*
  
  YESNO
- Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)?*
  
  YESNO
- Have you been advised by a doctor to self-isolate at this time?*
  
  YESNO
- Have you been advised by a doctor to cocoon at this time?*
  
  YESNO
- Have you travelled abroad in the last 14 days?*
  
  YESNO
- If Yes, please state the country you have travelled to and the date of your return
- Name of Country*
- NA 1
- NA 2
- Date of return to Ireland*
  
  DayMonthYear
  Date
- If in response to any of the questions above, you have selected 'YES', you are advised to contact your Manager and seek medical advice prior to your return to the workplace.
  
  Any false information given could result in disciplinary action, up to and including dismissal.
- Employee Name*
  FULL NAME, SURNAME
- Date of Completion*
  
  DayMonthYear
  Date
  Hour MinutesAM/PM Option
- Anticipate Return to Work Date*
  
  DayMonthYear
  Date
- Employee Signature*
- Should be Empty:

Return to Work Declaration Form