Agencies Return to Work Form

This form is to be completed prior to the return to site of any agency worker. The agency should complete this with their worker prior to return and share a copy with BCA Fleet Solutions if requested. Any information will be processed in accordance with BCA’s Data Protection Policy.

Agency Worker Name:

Site/Location of Work:

Agency engaged with:

Date: October 11, 2026

Ask them for an update regarding their personal circumstances. Please check through each of the following and record their response.

1. Are you considered very high risk (i.e. shielding because you are clinically extremely vulnerable and have received an NHS letter)?

2.Are you considered high risk i.e. you fall into the following categories: -

• 70 or older
• Are pregnant
• Have a lung condition that is 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)

3.Do you have young children at home and therefore have childcare issues?

4.Do you live with someone who is clinically vulnerable/shielding? NOTE: extremely clinically vulnerable individuals have been strongly advised not to work outside the home.

5.Have you experienced any cold or flu-like symptoms in the last 14 days (including fever, cough, sore throat, respiratory illness, difficulty breathing)?

6.Have you returned from any overseas country within the last 14 days?

7.Have you had close contact with or cared for someone diagnosed with or showing signs of Covid-19 within the last 14 days?

8.Have you been in close contact with anyone who has travelled abroad within the last 14 days to any overseas country?