Risk assessment – Vulnerable groups COVID-19

COVID -19 RISK ASSESMENT FOR HEALTH CARE WORKERS

Personal Information

Title

DOB

Name *

. *

Address

Home Tel

Work Tel

GP Address

COVID – 19 Medical History

Have you suffered from any?COVID – 19Period of IsolationDate Isolation finishedDid you get tested by the health service if so, please write which location i.e. Hospital?

Date of Testing

Result of Testing

Additional Information

(If you have answered yes to any questions above please provide additional information below, including dates, treatment and details of condition)

Have you lived outside the UK or had an extended holiday outside the UK in the last year?YesNo

If you answered YES to the above, please list all the countries that you have lived in/visited over the last year, including holidays and vacations. This MUST include duration of stay and dates or this form will be rejected. *

Additional Information

(If you have answered yes to any questions above please provide additional information below)

The General Data Protection Regulation (GDPR) (EU) 2016/679

All information supplied by you will be held in confidence by Care Mint. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. You have the right of erasure (the right to be forgotten), withdrawal of consent and refusal of consent without detriment. The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation.

Declaration

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Date

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COVID -19 RISK ASSESMENT FOR HEALTH CARE WORKERS

Personal Information

COVID – 19 Medical History

Additional Information

Additional Information

Declaration

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