Team Return To Work

Dear Clinicians and Staff members,

We take the health and safety of our teams very seriously. This is particularly the case because we are considered critical workers and have a duty of care to ensure safety of our family and our patients.

Prior to reopening to routine patient care, we would like all of you to complete this form so that we are aware of your current relevant medical status, opinions and risk level with regards to coronavirus infection.

It is important that you have thoroughly read, understood and agree to abide by the latest Standard Operating Procedure of 1st June 2020 prior to completing this form.

Please complete as thoroughly as possible as you will not be permitted to start work until this has been completed. 

If you have any questions please refer to our practice manager or clinical directors.

Thank you for your co-operation.

Keep Safe, Keep Well and Keep Alert

Return to Work Declaration

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I confirm that we have a training session to include (1) fit testing (2) discuss the SOP and RRR (3) Role play scenarios (4) raise, clarify and resolve any concerns relating to my duties and role at the practice
I confirm that I have read, understood and agree to abide by the latest Standard Operating Procedure (SOP) and Risk Reduction Recommendations (RRR) Version 1.0

IMPORTANT (Please tick all that apply)

In the last three weeks have you been in communication with someone who has or may may have COVID-19 (coronavirus infection) or had any of the following?
Based on your activity over the last 2 weeks, how would you subjectively classify your risk of being exposed to or infected by COVID-19?
I am confident that our standard cross infection control protocols and additional measures outlined in our updated Standard Operating Procedure are adequate for patient and staff safety from coronavirus cross-infection prevention

Thanks for submitting!