COVID-19 Staff consent

COVID Consent: Staff

COVID Consent: CRGW Staff

Today's date*
DD slash MM slash YYYY

(dd/mm/yyyy)
Name*
Telephone Number*
Email*
Enter Email Confirm Email
Are you aware of the risks of COVID-19 in pregnancy?*
Before considering treatment, patients must be fully informed of the risks related to COVID-19 including potential increased risk when attending clinic (particularly if they travel on public transport). Though you dont need to have read the document it is important to be aware of its existence (patients are consenting that they are aware of it before their treatments re-start). www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/ PLEASE SEE LINK AT TOP OF PAGE FOR RCOG GUIDANCE
I will follow the COVID-19 code of conduct*
I will: 1) avoid unnecessary exposure to risks of Covid-19 infection at work and in private 2) restrict interactions in line with government guidelines on social distancing and remaining at home, where appropriate 3) provide CRGW with updates regarding my health and wellbeing and whether I have infringed the code of conduct and been potentially exposed to Covid-19
Do you have any of the following symptoms?*
A high temperature (fever). A new continuous cough. A loss of smell or taste (anosmia).
Are you at an increased risk of a severe illness from the coronavirus (COVID-19)? For example:*
1) Have had an organ transplant 2) Are having certain types of cancer treatment 3) Have had blood or bone marrow cancer, such as leukaemia 4) Have a severe lung condition, such as cystic fibrosis, COPD or severe asthma 5) Have a condition that makes you much more likely to get infections 6) Are taking medicine that weakens your immune system 7) Diabetic 8) Are pregnant and have a serious heart condition
Have you (or your partner if applicable) returned from any countries outside of the UK within the last 14 days*
Have you (or your partner if applicable) had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*
Have you (or your partner if applicable) been in close contact with anyone who has traveled within the last 14 days to any country listed as a COVID-19 infectious area?*
Have you (or your partner if applicable) experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)*
Are you (or your partner if applicable) shielding from COVID-19 or live with people who are shielding?*
*Shielding is when people vulnerable to COVID-19 self isolate
I am aware that if suspected of infection I will be referred for testing and not work until the symptoms have cleared or as in line with national guidelines?*
I am aware that testing and quarantine of staff will be in accordance with current best practice guidance (as it develops) issued from Public Health England / Wales & Department of Health and Social Care?*
I am aware that if I test positive for Covid-19 I will receive occupational health advice and remain in self quarantine until advised it is safe to return to work?*
I am aware that as contact tracing technology (such as a COVID-19 app) becomes available that CRGW encourage its use for all staff?*
I am aware that PPE for CRGW staff where required will be used in accordance with Public Health England guidance: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control? SEE TOP OF PAGE FOR LINK.*
Electronic signature*

My electronic signature below confirms I have read and understand the COVID-19 specific information above.
Email
This field is for validation purposes and should be left unchanged.