First Name * Last Name * Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20192020202120222023 Are you or anyone you live with under any form of self-isolation as the result of an order of any government authority or as the result of a recommendation of a health professional? * Yes No Are you or anyone you live with waiting for the results of a COVID-19 test? * Yes No Are you suffering from any flu-like symptoms (including a sore throat, fever, tiredness or cough)? * Yes No Please contact your manager for approval to work Confirmation * I confirm that the information provided by me in my Original Health Declaration has not changed and that I am not suffering from any flu-like symptoms (including a sore throat, fever, tiredness or cough). My information provided by me in my Original Health Declaration has changed.
