Visitors and Contractors Health Questionnaire

Declaration

A dry persistent cough, and or fever (high temperature > 37.8 C)

Skin Disease (eczema, dermatitis, psoriasis)

Stomach or bowel disorders

Jaundice or Hepatitis

Food poisoning symptoms

Hearing loss/discharging ears

Fits, blackouts, migraines

Have you been abroad in the last 28 days?

If YES, please state where?

If YES, did you have to seek medical advice for any symptoms you have been displaying?

Have you been in contact with anyone who is/has been suffering with any of the above within the last 48 hours?

Have you ever had or are you known to be a carrier of typhoid or paratyphoid?

Have you visited another food premises today?

If YES, what products were they handling?

I declare that

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carrying recording or photographic equipment

I declare that

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carrying any personal medication

I declare that

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carrying any allergens on my person or belongings

I declare that

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read and understood the notice QMIC-C Version 2.4 regarding instructions to Visitors (including contractors).

By clicking this box, I declare that to the best of my knowledge, the information given in this document is true and accurate. I do not suffer from  any illness or disability, which is likely to cause a food safety or a health and safety hazard.

QMCVH-Q

JUNE 20

Version 2.3