Coronavirus Daily Health Check Form

    Your Full Name*

    Your Email*

    Is there a health care worker living in your household?*
    YesNo

    Do you have symptoms of coronavirus? A high temperature, a new continuous cough or loss of taste and smell?*
    YesNo

    If Yes, you must not come to work. You must self-isolate for 7 days.
    Please click here for further guidance on what to do next.

    Do you live with someone that has symptoms of coronavirus?*
    YesNo

    If Yes, you must not come to work. You must self-isolate for 14 days.
    Please click here for further guidance on what to do next.

    Have you within the last 10 days returned from a country which would require you to self-isolate on entry to the UK?*

    Have you within the last 10 days been instructed to self-isolate by NHS Test & Trace or any public health or medical professional?*

    Are you one of the vulnerable groups?*

    • Over 70
    • Under 70 and have an underlying health condition
    • Pregnant
    YesNo

    If yes please contact us

    Have you had a Coronavirus test in the last month?*
    YesNo

    Please enter the date of your test*

    Was your test negative or positive?*

    Your Message

    I confirm I have answered these questions truthfully and I understand I may be prosecuted if I knowingly give false information.

    Yes

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