Covid Return to Work Sign In form

• Conducted on

  Date

• Prepared by

• Employee Name

• Manager Name

• Workplace Address
  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?

  Yes

  No

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

  Yes

  No

• 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)?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• 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.

Sign Off

• Name and Signature

  Sign