Appendix 2 – UK AGENCY SELF ATTESTATION FORM

Adecco Self-Attestation Form

UK COVID-19 Attestation Form
Temporary Associate:
If applicable, please complete this form to confirm that you are claiming sickness leave for a reason which
meets the criteria for special sick pay related to COVID-19. To be eligible to claim special sick pay, you must:
1. Have worked on temporary assignment to Amazon for at least four weeks prior to the start of the
sickness absence;
2. Not have had a previous instance of COVID-19 related sickness absence; and
3. Have been quarantined for one of the six COVID-19 related reasons set out below.
Fraud or Misrepresentation
Providing false or misleading information, or omitting material information, in connection with any request for
sickness leave or special sick pay related to COVID-19 may result in disciplinary action, up to and including
termination or your temporary assignment to Amazon and your employment with Adecco.

Attestation
I confirm that I meet the standards for being quarantined for at least one of the six COVID-19 related reasons
listed below):
1. You have been medically diagnosed with COVID-19, or
2. You have been individually directed to quarantine by Amazon related to work place exposure to
COVID-19, or
3. You have been individually directed by the government or a public health agency not to go to work
related to your own illness or exposure to COVID-19, or
4. You have been told by your own health care provider that you must be quarantined related to COVID-
19, or
5. You believe you must be quarantined due to close contact with someone who has been confirmed
positive for COVID-19 (close contact is defined as being within approximately 6 feet (2 metres) of a
COVID-19 case for a prolonged period of time, or having direct contact with infectious secretions of a
COVID-19 case such as being coughed on), or
6. You believe you have COVID-19 because you have had two or more of these symptoms for a minimum
of three consecutive days:
a. Fever of 37.8 degrees Celsius or above
b. Cough, typically dry and non-productive
c. Shortness of breath, at rest and worsening
d. Sore throat, difficulty swallowing

By agreeing to the statement below, and signing this document, I certify that all of the information above is
true and accurate. I agree and acknowledge that I am expressly prohibited from making any misstatement or
material omission in this request, and that making a misstatement or material omission in this sickness leave
request may result in the denial of sickness leave and/or special sick pay and/or disciplinary action up to and
including termination of my temporary assignment to Amazon and my employment with Adecco.

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