OCCUPATIONAL HEALTH, SAFETY AND ENVIRONMENT

COVID-19 Pre-arrival Agency Questionnaire

In light of the ongoing COVID-19 coronavirus outbreak, Zotefoams is implementing measures to reduce the risk of infection for its staff and visitors, including pre-arrival screening of all new staff.

Please complete this questionnaire and return to your site contact and do not proceed to site until your contact confirms that you are approved to do so.

Thank you for your co-operation.

NB: Your data will be processed in accordance with the attached GDPR privacy notice. Completing the information below signifies agreement with the terms of the notice.

    Your details:






    Site contact:





    1. Have you had a test for COVID-19?*

      YesNo

      • If yes what was the result?

        PositiveNegative

    2. Have you had direct contact with anyone who has tested positive for COVID-19?*

      YesNo

    3. Have you visited any other countries in the last 14 days?*

      YesNo

      • If yes, please list:

    4. Are you experiencing any of the 3 main symptoms of COVID-19 (a fever, continuous dry cough, loss of or change in your normal sense of taste or smell)?*

      YesNo

      • If yes, please give details:

    5. Is anyone in direct contact to you experiencing any of the symptoms of COVID-19?*

      YesNo

      • If yes, please give details:

    6. Have at any point since the start of the COVID-19 pandemic have you had to self-isolate?*

      YesNo

      • If yes, please give details:

    7. In the last 14 days have you had any direct contact with anyone that has been self isolating?*

      YesNo

    8. In the last 14 days have you visited anywhere in the UK that was under lockdown or restricted social distancing measures?*

      YesNo

      • If yes, please state where:

    *Required fields

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