COVID-19 Self Isolation Form
In light of the current outbreak of COVID-19, we are doing all that we can to keep our Team Members safe. Please complete this form if you have been advised to self-isolate due to Coronavirus.
Please ensure that you oblige to the following self-isolation rules:
14 days of isolation
2m (6ft) away from anybody
Do not go to public places
Do not go on public transport or use taxis
Do not go out to get food and medicine – order it online or by phone, or ask someone to bring it to your home
Do not have visitors in your home, including friends and family – except for people providing essential care
Do not go out to exercise – exercise at home or in your garden, if you have one
Check all reasons for self-isolation that apply
You are showing symptoms of COVID-19 and have been told to self-isolate You live with someone who is showing symptoms of COVID-19 and have been told to self-isolate You have returned travel from a restricted destination You have tested positive for COVID-19
Employee Name
Position
Store Location
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Employee Email
example@example.com
Employee Phone Number
Please enter a valid phone number.
Employee Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Start Date of Self-Isolation
Month Day Year
Date
End Date of Self-Isolation
Month Day Year
Date
This form has been completed to the best of my knowledge. I confirm that I fall into one of the following three categories:
I am designated as a vulnerable individual and have been told to self-isolate.
I am showing symptoms of COVID-19 and have been told to self-isolate.
I live with someone who is showing symptoms of COVId-19 and have been told to self-isolate.
I confirm that I have uploaded an appropriate sick note confirming my instruction to self-isolate.
Date
Month Day Year
Date
Signature
Clear
Should be Empty:

COVID-19 Self Isolation Form