Form: Health Self-Declaration (Contractor)
Due to the ongoing and rapidly changing situation with the novel – coronavirus (COVID-19), we are
requiring all visitors to college premises to fill-out the self-declaration form below. The college will decide on
access to the premises based on the answers provided below.

Each visitor must complete this form 48 hours prior to your appointment, and await confirmation from the College that you are cleared to attend site.

The college reserves the right to deny entry to the premises.

All data is collected and will be processed in compliance with the College's Privacy Policy and the General Data Protection Regulations 2019.
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Full Name *
Company Name *
Date and time of visit to College *
MM
/
DD
/
YYYY
Time
:
Reason for attending site *
Who is your NCH contact? *
Do you have any of the following flu-like symptoms? *
Yes
No
Fever (38 ℃ or higher)
Cough
Breathlessness
Sore throat
Loss of taste or smell
Have you or any immediate family member come in close contact with a confirmed case of thecoronavirus in the last 14 days? (“Close contact” means being at a distance of less than one metre for more than 15 minutes.) *
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