Covid19 Pre-return form

I know this form is slightly repetitive, sorry about that.

Pre return form.


Do not return to work if the following apply –


  • If you are awaiting the result of a Covid19 test
  • If you are self isolating
  • if you have been sick without being diagnosed or confirmation that you have totally recovered (if in any doubt contact the Supervisor)
  • If you have any of the symptoms or fall into a category as describe below
  • If you in a vulnerable group
  • If you believe to have been exposed to someone who is likely to be infected or is


In general, the rule is its better to be safe than sorry and be cautious.


  • An underlying medical condition or in contact with someone with an underlying medical condition or who would be classed a vulnerable? Yes/no
  • Have you a temperature, fever and/or feeling sick? Yes/no
  • Experience any difficult in breathing or shortness of breath? Yes/no
  • If you have any of the above symptoms, did you consult a doctor or other medical practitioner?
  • Have you been in contact with someone who has visited an affected

region in the past 14 days Yes / No?

  • Have you been told to cocoon at this time? Yes/no


If the answer is yes to any of the above questions don’t return to work until you have been cleared to do so.




Area of work:


Sign                        ______________________________________


Date                        ______________________________________



These may seem obvious but: –



  • There is a no handshaking policy
  • Ideally work in isolation, if not ensure that there is a minimum of 6 feet apart ideally 10 feet or more.
  • Do no use tea rooms or places you are likely to meet, use own cars or similar.  All tea/rest rooms are closed.
  • If using toilets ensure that door handles and surfaces are sprayed and cleaned down disinfectant and clean hands.  Ideally touch as few surfaces as possible and use the public toilets as little as possible.
  • At time of writing, there will be no timesheets.
  • Be aware that if you are unable to block a cough or sneeze, do so into your elbow.
  • Please ensure you fill in the contact sheet everyday
This entry was posted in Uncategorized. Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s