COVID – KHR Forms

First Name:*

Last Name:*

1. Do you have any of the following flu-like symptoms:

Choose any that apply

Details:

2. Please list any countries/cities you have travelled to in the last 14 days prior to to today's date:

Click the + to add more lines if you need to

Name of Country/City	Date of Arrival	Date of Departure

3. Have you or an immediate family member come in to close contact with a confirmed case of the coronavirus in the last 14 days?*

“Close contact” means being at a distance of less than one metre for more than 15 minutes.

I agree that this document will be retained confidentially by the company for one month after submission.*

I agree that the health and wellbeing of staff is the first priority of KHR and my employer reserves the right to deny entry to the site.*

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