COVID-19 - Declaration of fitness

Employee ID

First Name

Last Name

Phone

Site

Floor

Do you have an existing respiratory condition (such as asthma)?

Do you have a fever?

Do you have a cough?

Are you lethargic?

Do you have any difficulty breathing or shortness of breath?

You have indicated you have an existing condition or symptoms that may affect your immune system, do you have medical clearance to work?

Guard needs to be cleared for duty - please contact manager. Include comments

Do you declare that

to the best of your knowledge and belief you are physically fit and there is no other medical condition or illness likely to prevent you from performing duties effectively as a security officer
to the best of your knowledge the information provided in this application is true and correct

Do you declare you are fit to work?

Form completed by

Name of person completing form

Date

Time