Declaration – Illness reporting (Covid 19)

Employee Name

Employee Number Outlet

Designation Completed by

Please answer the following questions to the best of your ability and knowledge.
If the employee is not available in person, complete the from on their behalf
communicating the below questions.

1.Are you currently suffering from any of the below symptoms?

Flu Yes No Sore Throat Yes No

Shortness of Breath Yes No Runny Nose Yes No

Difficulty Breathing Yes No Diarrhea Yes No

Cough Yes No Vomiting Yes No

Fever Yes No Tiredness / Fatigue Yes No

2. If you have answered yes to any of the above questions can you provide more detail
on how long you have been suffering with this / these symptoms and the severity.

3. Is anyone within your residence currently in the process of having Yes No

a COVID19 test?

4. Have you come into contact with anyone who has tested positive Yes No
for COVID19?

5. If you have answered yes to question 3 or 4 can you provide further details below.
Please provide evidence of any positive COVID19 test.

Last working date at outlet:

I have, to the best of my knowledge, have answered the

above questions honestly and accurately at the time of completing this declaration.

Signed Date