GEFCO Medical Information and Consent FORM GEFCO Medical Information and Consent Form Your DetailsIgloo worker name* First Email* Q1: Have you been tested for COVID 19?*YesNoIf 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?*YesNo 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?*YesNoIf 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?*YesNoIf 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?*YesNoIf yes, please detail below:Q6: Are you taking any specific medication in relation to COVID 19?*YesNoIf 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?*YesNoIf 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?*YesNoIf 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.TO 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
