Agencies Return to Work FORM Agencies Return to Work Form Your DetailsFull Name* First Email* Site/Location of work*Agency engaged with*Are you considered very high risk (i.e shielding because you are clinically extremely vulnerable and have received an NHS letter)?*NoYesAre you considered high risk i.e you fall into the following categories*NoYes 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) Do you have young children at home and therefore have childcare issues?*NoYesDo you live with someone who is clinically vulnerable/shielding? NOTE: extremely clinically vulnerable individuals have been strongly advised not to work outside the home*NoYesHave you experienced any cold or flu-like symptoms in the last 14 days (including fever, cough, sore throat, respiratory illness, difficulty breathing)?*NoYesHave you returned from any overseas country within the last 14 days?*NoYesHave you had close contact with or cared for someone diagnosed with or showing signs of Covid-19 within the last 14 days?*NoYesHave you been in close contact with anyone who has travelled abroad within the last 14 days to any overseas country?*NoYesTO CONTINUE PLEASE CLICK SUBMIT AND READ THROUGH THE DOCUMENT THEN SIGN AT THE BOTTOM. CLICK AGREE AND SIGN THIS WILL SEND THE DOCUMENT BACK TO IGLOO
