Recruitment Interviewee Pre-visit Questionnaire

Part 1

This Health Information Questionnaire is designed to demonstrate that Hendra Holiday Park has considered current situations involved with recruitment surrounding the Coronavirus (COVID-19) guidelines. This questionnaire is in place to help protect both our staff and the interviewee from contracting Covid-19. Information supplied in this questionnaire may need to be forwarded to Gov.uk for the purpose of Coronavirus management.

Candidates Name*

Meeting Place*

Position Applied For*

Date of Interview*

Interviewing Manager*

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Have you contracted Coronavirus?*

Yes
No

Have you been tested for Coronavirus?*

Yes
No

If you have been tested, what was the date of your last test?

If you have been tested, what was the result?

Positive
Negative

Have you experienced any of the following symptoms at present or in the last 10 days?

Cough*

Yes
No

Shortness of Breath*

Yes
No

High Temperature*

Yes
No

Loss of Taste or Smell*

Yes
No

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Have you recently travelled outside the UK?*

Yes
No

If yes, please state which contries and the dates you travelled.

Have you knowingly come into contact with someone displaying the symptoms of the virus or someone who has been confirmed as a carrier?*

Yes
No

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Part 2

In order to fully protect you during the interview process please tell us if you fall into any of the vulnerable categories listed below, this information will only be used to identify if we need to make any special measures or provisions under current Government guidelines to keep you in a safe environment, you do not need to tell us what your vulnerability is, just let us know what category if any that you fall into. Please answer Yes or No if you fall into any of the following category descriptions.

Clinically Extremely Vulnerable*

Yes
No

Clinically Extremely Vulnerable: Have had an organ transplant, are having chemotherapy or antibody treatment for cancer, including immunotherapy, are having an intense course of radiotherapy (radical radiotherapy) for lung cancer, are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors), have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma), have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine, have been told by a doctor you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD), have a condition that means you have a very high risk of getting infections (such as SCID or sickle cell), are taking medicine that makes you much more likely to get infections (such as high doses of steroids or immunosuppressant medicine), have a serious heart condition and are pregnant, have a problem with your spleen or your spleen has been removed (splenectomy), are an adult with Down's syndrome, are an adult who is having dialysis or has severe (stage 5) long-term kidney disease, have been classed as clinically extremely vulnerable, based on clinical judgement and an assessment of your needs.

Clinically Vulnerable*

Yes
No

Clinically Vulnerable: Are 70 or older, have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis), have heart disease (such as heart failure), have diabetes, have chronic kidney disease, have liver disease (such as hepatitis), have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy), have a condition that means they have a high risk of getting infections, are taking medicine that can affect the immune system (such as low doses of steroids), are very obese (a BMI of 40 or above), are pregnant.

Other factors that can affect your risk:*

Yes
No

Over 60 – your risk increases as you get older or if you are from a Black, Asian or minority ethnic background (BAME)

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I confirm that the above information is accurate to the best of my knowledge and I agree to comply with all hygiene and social distancing procedures whilst present on site.*

Yes
No

Hendra Holiday Park