Location and health declaration form

To prevent the spread of novel coronavirus in our community and reduce the risk of exposure to our students, staff and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in our building. Please complete the questionnaire and submit it before you visit ELH.

You must complete this form:

Before your first visit to ELH or
If you or someone you have come into contact with is showing symptoms of Covid, has Covid and/or is awaiting the results of a Covid test. In this instance please do not come to ELH until you can email us the results of your Covid test showing that you do not have the virus.
If you have travelled to a high risk Covid area.

If you or someone you have come into contact with is showing symptoms of a Covid infection or if you have travelled to a high risk Covid area, you may need to self isolate for 14 days before you return to ELH

LOCATION AND HEALTH DECLARATION FORM

Health Screening Form for Student, Staff and Visitors to ELH

* Indicates required field

Name *

First

Last

Email *

Mobile Number *

Address in the UK *

Line 1

Line 2

City

State

Zip Code

Country

Landline Number *

Nationality *

Age range: *

Reason for coming to ELH *

Please tell us which countries you have lived in, visited, travelled to or travelled through (in transit) in the last 30days. Also give us the dates you visited, travelled through. eg Ireland from 5th October to 7th October 2020

Names of these countries and dates you visited: *

Self Declaration:

1) Have you been in contact with a confirmed Coronavirus (COVID-19) patient in the past 14 days? *

See coronavirus-covid-19-travel-corridors

2) Have you been to any countries that are not on the list? *

See coronavirus-covid-19/symptoms

3) Have you had or are you experiencing any symptoms of coronavirus? *

4) Have you come into contact with anyone who has been experiencing symptoms of coronavirus? *

5) If "yes" please expand here: *

Please submit this form at least 24 hours before your visit

Submit