Title Page
- Sign-in
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Name
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Sign-in Date and Time
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Company
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Phone Number
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Have you now, or have you over the last seven days, suffered from diarrhoea and/or vomiting?
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Have you had cause to visit a GP within the last month due to diarrhoea and/or vomiting?
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At present are you suffering from septic lesions:<br> I. Of the hands?<br> ii. Of the nose and/or throat?<br> iii. Eye's and/or ears?<br>
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Have you ever had, or are you now known to be a carrier of Hepatitis A?
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I declare that the statements above are true and completed to the best of my knowledge. I understand that it is a disciplinary offence to give a false statement to the above questions and that I could make myself liable if an incident arises as a result of any false statements.
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Sign-out Date and Time
