Template

Coronavirus Self-Declaration Form

by Saurabh Mathur, from the Community

10+

Use this Coronavirus Self-Declaration Form to pre-screen employees, contractors, and visitors before they access a worksite or facility. The checklist captures personal details, recent symptoms, high-risk medical conditions, recent travel or close contact history, age and vulnerability factors, and acknowledgement of current site safety protocols, PPE, and hygiene requirements. If any risk indicators are present, the respondent is instructed not to enter and to contact their manager. Customize fields to align with your jurisdiction and company policy, and securely store responses for compliance.

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With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions .

Template
Return to Work COVID-19 Health Declaration
This return to work COVID-19 health declaration helps organizations screen employees and contractors before reentry to the workplace. The form captures recent symptoms, diagnosis, close contacts, travel history, and at risk factors, and directs workers to contact supervisors or HR when needed. It outlines self isolation and restricted movement guidance, identifies high risk groups, and includes sign off to confirm accurate information for a safer return.
by Declan Dixon, from the Community
Downloads: 40+
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Template
COVID-19 Self-Declaration Form
Use this COVID-19 self-declaration checklist to assess staff, contractors, and visitors for potential exposure and symptoms prior to entering a site or appointment. Record personal details, travel history or contact exposure, symptom checks, and temperature readings. Reinforce hygiene, PPE use, and social distancing practices to reduce transmission risk. Ideal for workplaces seeking a simple, consistent screening process during outbreaks.
by M Gibbs, from the Community
Downloads: 100+
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Template
Covid 19 Visitor Questionnaire
Use this Covid 19 Visitor Questionnaire to screen visitors before they enter your workplace. Capture names, contact details, visit purpose, recent travel, symptoms, and close contact history to identify risk and decide on access. Reinforce on site hygiene and self isolation guidance to protect staff and customers. This template is a general example and should be reviewed against your local policies and regulations.
by Rian O'Flaherty, from the Community
Downloads: 20+
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Template
COVID-19 Return to Work Sign-In Form
This return to work sign-in form helps organizations screen staff before re-entry to the workplace. It records employee and manager details, asks about COVID-19 symptoms, recent diagnosis, close contact and medical advice to self-isolate, and captures additional notes. Employees provide a signature to confirm declarations. Use as a guidance template and adapt to your policies and local regulations.
by SafetyCulture
Downloads: 20+
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Coronavirus Self-Declaration Form

About author

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Return to Work COVID-19 Health Declaration

COVID-19 Self-Declaration Form

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Return to Work COVID-19 Health Declaration

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