Please answer the following questions to help us assess your suitability for work, given the ongoing issues relating to coronavirus (COVID-19). Name* First Last Email* In the past 14 days...Have you travelled in any of the identified COVID-19 (Coronavirus) affected areas? (as of 02.03.2020) e.g Northern Italy (anywhere north of Pisa, Florence and Rimini), Tenerife, China, Iran, Japan, Singapore, South Korea, Hong Kong.* Yes No COVID-19 Affected countries are listed on the gov.uk website HERE.Have you been in contact with a person who has COVID-19 (Coronavirus)?* Yes No Have you attended a hospital/healthcare facility where patients with COVID-19 (Coronavirus) are being treated?* Yes No As you've answered 'no' to one or more of the questions above please contact 111 or self-assess at https://111.nhs.uk/covid-19 and get advice regarding your immediate working status.As you have said yes to one or more of the above statements if you feel unwell with respiratory symptoms (e.g. a cough, high temperature, shortness of breath, difficulty breathing), YOU WILL NOT BE AUTHORISED ONTO SITE Please isolate yourself (i.e. stay separate from other people) and phone your GP/ 111 or self-assess at https://111.nhs.uk/covid-19 immediatelyAs you have said NO to any of the above questions, but have symptoms and concerns, you may have contracted COVID-19 (coronavirus). Please isolate yourself (i.e. stay separate from other people) and phone your GP / 111 or self-assess at https://111.nhs.uk/covid-19 immediately.Authorisation to workAs you've answered 'yes' to one of the above questions, have you contacted 111 or self-assessed online and been given authorisation to work?* Yes No Self-assessment online should be carried out here: https://111.nhs.uk/covid-19As you've been given authorisation to work, please proceed to site. Please tick the declaration checkbox below and submit this form'No' to everythingAs you have answered 'NO' to everything asked above, please read through our advice on our website HERE on COVID-19 before attending shift.Complete your COVID-19 declarationDeclaration* I confirm that the information I've entered into this form is accurate and true.Please click the submit button below to send this form to the Bluestones Medical team. NameThis field is for validation purposes and should be left unchanged.
