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Name*
DD slash MM slash YYYY
To the best of your knowledge have you any symptoms of Covid-19, i.e. cough, fever, shortness of breath, sore throat, runny nose or flu like symptoms – now or in past 14 days?
Are you self-isolating?
Are you awaiting results of a test relevant to Covid-19
Have you been diagnosed with confirmed or suspected Covid-19 infection in last 14 days?
Are you a close contact of a person who is a confirmed or suspected case of Covid-19 in the past 14 days? (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day)
Have you been advised by a doctor to self-isolate or cocoon at this time?
I understand that One Family is committed to providing a safe and healthy workplace for all its staff and service users, I nevertheless accept the risk of the possibility of infection by engaging in face to face sessions.*
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