Please add your full name to the below declaration, check that the date is the date that you will be attending the workplace and send your confirmed Declaration back to us by return email.

If you are unable to sign the Declaration because not all of the statements apply to you then you will not be able to enter the workplace and you should let us know this immediately by separate email.

You will not be admitted to the workplace unless you have sent us a confirmed Declaration for the day concerned.

All staff are required to declare their health status daily before attending/entering Blossom Healthcare Solutions Ltd | Unit E Warwick House | Perry Road | Harlow-Essex | CM18 7NF

Declaration

I declare and confirm that to the best of my knowledge and belief on the above date:

Please tick ALL the statements below to confirm that they are true

I do not have a new continuous cough;

I do not have a temperature;

I have not lost my sense of taste or smell;

I do not feel generally unwell;

I do not share a home with anyone who is self-isolating;

I have not come into contact with anyone who is now confirmed or suspected to be positive for Covid-19; and

I have been complying with all of the Government's social distancing rules at all times.

By sending this declaration I confirm that the 7 statements above are true and apply to me on today’s date.” Please ensure your full name is included in your reply/declaration.

On arrival and departure of Blossom Healthcare premises your temperature will be taken and a record will be kept. Normal recommended human temperature is 36.5°C, any temperature that is above 37.8°C will not be permitted into the building.

Please sanitize on entry and exit.

Prior arrangement must be made with the office before coming to the premises so only fill out this form if arrangement has been made.

Please view our current Risk Assessment