Template

Return to Work COVID-19 Health Declaration

by Declan Dixon, from the Community

40+

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.

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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
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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Template
School Staff COVID-19 Sign-In and Health Declaration
This School Staff COVID-19 sign-in and health declaration template helps schools screen staff before entry each day. It captures date, name, school and principal details, asks about symptoms, recent diagnosis, close contacts, self-isolation and high-risk status, and records sign-off to confirm fitness for work. Use it to support safe, compliant school operations and contact tracing.
by SafetyCulture
Downloads: 20+
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Template
COVID-19 Return to Work Record
Use this COVID-19 Return to Work Record to document employee details, absence history, and a safe return-to-work induction. Capture symptom checks, confirm PPE issued, brief staff on updated COVID-19 safety measures, and complete manager sign-off for HR compliance. This customizable template supports organizations in standardizing their return-to-work process, maintaining records for audits, and promoting a safe, compliant workplace during reopening and ongoing operations.
by Beth Reed, from the Community
Downloads: 200+
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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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Return to Work COVID-19 Health Declaration

With SafetyCulture you can

Digitize team workflows

Reduce manual errors

Create and share inspection reports

About author

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COVID-19 Self-Declaration Form

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COVID-19 Return to Work Sign-In Form

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