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COVID-19 Return To Work Form

To ensure the Safety, Health, and Wellbeing of all people working at Burnside Autocyl, all employees must complete this declaration form prior to returning to work after annual holiday closure commencing on the 18/12/2020.

If you indicate to us, you have symptoms of COVID-19 OR you have been abroad in the last 14 days you should not be at work.

Where this is the case, you are prohibited from entering the premises and should make contact with your immediate boss by phone before returning.
All employees must complete this form before returning to work on Monday 4th January or, any date later than this.

Employee Name (required)

Clock Number (required)

Click Todays Date:
1. Have you or, any member of your household visited any country outside Ireland within the last 14 days? YesNo

2. Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? YesNo

3. Have you or, any member of your household been in close contact with a person diagnosed with COVID-19 within the last 14 days? YesNo

4. Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day)? YesNo

5. Have you been free of fever (37.8°C, 100°F, or greater using an oral thermometer) and any other symptoms for at least 24 hours, without the use of fever-reducing or other symptom-altering medicines? YesNo

6. Have you been diagnosed with confirmed or suspected COVID-19 infections in the las 14 days? YesNo

7. Have you been advised by a doctor to cocoon or self-isolate at this time? YesNo

8. Have you had any person from outside Ireland in your household within the last 14 days? YesNo

9. Please provide details below of any other circumstances relating to COVID-19, not included in the above, which may need to be considered to allow your safe return to work.

*If your situation changes after you complete and submit this form, please tell management immediately.
I declare that I have answered the above questions truthfully and to the best of my knowledge.
Please Enter Employee Name Again (required)

Click Todays Date: