Title Page

  • Conducted on

  • Prepared by

  • Employee Name

  • Manager Name

  • Workplace Address


  • Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, flu like symptoms or loss or change to your sense of smell or taste now or in the past 14 days?

  • Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?

  • 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 2 metres for more than 15 minutes altogether in 1 day)?

  • Have you been advised by a doctor to self-isolate at this time?

  • Have you been advised by a doctor to cocoon at this time?

  • Please provide details* below of any other circumstances relating to COVID-19, not included in the above, which may need to be considered to allow your safe return to work.

  • Additional Information

  • * If you are unsure whether or not you are in an at-risk category, please check the information at the link in Question 6. If your situation changes after you complete and submit this form, please tell management.

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  • Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.