Covid-19 - | IWE Ltd

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If you indicate to us you have symptoms of COVID-19, or if you have been abroad in the last 14 days (with the exception to Northern Ireland), in accordance with Government guidance, you will not be permitted to enter the Company’s premises.

Name *

First

Last

Contact Phone Number *

Email *

Date / Time

Date

Time

Do you currently have, or have you ever been diagnosed as having, Covid-19? *

Yes
No

Have you travelled abroad in the last 14 days? *

Yes
No

If yes please state where

Have you displayed any symptoms of Covid-19 in the last 14 days, namely fever, high temperature, persistent coughing, breathing difficulties / shortness of breath, and. or loss of taste or smell? *

Yes
No

If yes, which symptom(s) have you displayed

Do you live in the same household as someone, or have been in close contact with someone, who has displayed symptoms of Covid-19 in the last 14 days or who has a confirmed case of Covid-19? *

Yes
No

If yes, please provide details:

If you answered Yes to any of the foregoing questions, have you consulted a Doctor or other medical practitioner? *

Yes
No

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

Yes
No

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

Yes
No

Do you travel alone to your place of work? *

Yes
No

Do you object to your temperature being taken before entering the premises? *

Yes
No

NOTE: When on site, please ensure you follow our direction in respect of Covid-19, to include our on- site standard procedures regarding infection control (e.g. hand washing/hand sanitising, general coughing/sneezing etiquette, etc.). Information supplied in this questionnaire may be shared with any of our employees that you come into contact with and/or with the relevant authorities for contact tracing purposes.

I confirm that the above information is accurate to the best of my knowledge:

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