To support your return to work and transition into the ongoing working arrangements during COVID. It is important that you provide the following key information and return the form to your line manager to review. The questions set out below are designed to highlight any additional risks or concerns raised which may need to be addressed prior to you returning to work.

The form is confidential and is kept on file with HR following a review and sign off by your manager. Further surveys maybe requested as the UK transitions through the COVID situation and GEFCO UK responds to further guidance issued by the government. It is important that during this time, any changes in both mental wellbeing and physical health are raised before attending work direct with your line manager.

You will be kept informed of measures to be implemented and GEFCO will continually review the risks and controls in place.

Igloo Worker Name:

Contact Details for Igloo: 01455 891358

Q1: Have you been tested for COVID 19?

If yes, please confirm below the results, outcome and treatment provided along with date test completed, date confirmed with / without COVID, date confirmed as no longer infected and any information provided to you by the medical experts to confirm you are fit to work:

Q2: Have you had any of the following Symptoms in the last 14 days?

• Persistent Coughing Episode
• Intense Fatigue Experienced
• Fever, High Temperature above 37.7
• Difficulty Breathing, Shortness of Breath
• Loss of Smell / Taste

If yes, please circle the symptoms had / ongoing and outline below when they started and what action you have taken to manage them:

Q3: Have you been in contact with anyone in the last 21 days who has been diagnosed or shown symptoms of COVID 19?

If yes, please confirm below the results, treatment provided along with date of test completed, date confirmed with / without COVID, date confirmed as no longer infected:

Q4: Do you have any known underlying medical condition which puts you at high risk from COVID 19?

If yes, please describe the condition and confirm you have spoken with your GP about you returning to work:

Q5: Are you a new expectant mother or returning to work whilst still breast feeding?

If yes, please detail below:

Q6: Are you taking any specific medication in relation to COVID 19?

If so, please specify below what you have: prescribed or non-prescribed, dosage and frequency per day:

Q7: Have you received a letter from the NHS, Government or Medical Practitioner confirming you are at risk and to self-isolate?

If yes, please detail below and to provide a copy when submitting the form:

Q8: Are you fit and able to work with no symptoms of COVID?

If you have any additional information you would like to add, please comment below:

If you have answered Q1 – 7 as yes or Q8 as no, please call your direct manager prior to attending site to discuss

The medical survey is to be brought with you upon your initial return to work if you are fit to return.