Pre-Return to Work Declaration - Hendra Holiday Park

Health Questionnaire

COVIC-19: Please tick below if you fall into any of the following categories Under Current legislation if you fall into the “Clinically Extremely Vulnerable” category you must shield and not go to work.

Clinically Extremely Vulnerable Group Questions

Have had an organ transplant

Yes
No

Are having chemotherapy or antibody treatment for cancer, including immunotherapy

Yes
No

Are having an intense course of radiotherapy (radical radiotherapy) for lung cancer

Yes
No

Are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)

Yes
No

Have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)

Yes
No

Have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine

Yes
No

Have been told by a doctor you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)

Yes
No

Have a condition that means you have a very high risk of getting infections (such as SCID or sickle cell)

Yes
No

Are taking medicine that makes you much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)

Yes
No

Have a serious heart condition and are pregnant

Yes
No

Have a problem with your spleen or your spleen has been removed (splenectomy)

Yes
No

Are an adult with Down's syndrome

Yes
No

Are an adult who is having dialysis or has severe (stage 5) long-term kidney disease

Yes
No

Have been classed as clinically extremely vulnerable, based on clinical judgement and an assessment of your needs

Yes
No

Clinically Vulnerable Group Questions

Are 70 or older

Yes
No

Have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)

Yes
No

Have heart disease (such as heart failure)

Yes
No

Have diabetes

Yes
No

Have chronic kidney disease

Yes
No

Have liver disease (such as hepatitis)

Yes
No

Have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)

Yes
No

Have a condition that means they have a high risk of getting infections

Yes
No

Are taking medicine that can affect the immune system (such as low doses of steroids)

Yes
No

Are very obese (a BMI of 40 or above)

Yes
No

Are pregnant ,as a precaution. This is because pregnant women can sometimes be more at risk from viruses like flu.

Yes
No

Vulnerable/Moderate Risk Group Questions

Over 60 – your risk increases as you get older

Yes
No

From a Black, Asian or minority ethnic background

Yes
No

If you are in the high risk (Clinically Extremely Vulnerable) category from coronavirus, you should have received or will receive a letter from the NHS to confirm this.

Declaration

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

Yes

You should not return to work until instructed to do so by your line manager. The information on this form will be stored in accordance with the UK Data Protection Act 2018.

I confirm I have read and understood the Welcome Back to Work Information Pack and associated Safe Working Procedures.*

Yes

Hendra Holiday Park

COVID-19 Pre-Return to Work Declaration for Employees [UK]

Step 1 of 2

Employee Details

COVID-19 Questionnaire

Do you consent to the below?

Health Questionnaire

Clinically Extremely Vulnerable Group Questions

Clinically Vulnerable Group Questions

Vulnerable/Moderate Risk Group Questions

Declaration

Start your new
Hendra adventure

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Hendra Holiday Park

COVID-19 Pre-Return to Work Declaration for Employees [UK]

Step 1 of 2

Employee Details

COVID-19 Questionnaire

Do you consent to the below?

Health Questionnaire

Clinically Extremely Vulnerable Group Questions

Clinically Vulnerable Group Questions

Vulnerable/Moderate Risk Group Questions

Declaration

Start your new Hendra adventure

Start your new
Hendra adventure