Location and health declaration form

LOCATION AND HEALTH DECLARATION FORM

Health Screening Form for Student, Staff and Visitors to ELH

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 this building.
Thank you for your time.

* 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: *

Disclaimer/Covid-19 rules - Disclaimer to be displayed on the website:
Warning - Risk of Covid-19 Covid–19, often referred to as coronavirus, is an infectious disease that can result in serious and potentially fatal illness. There is a risk of the transmission of Covid–19 in any environment where people come together. This risk increases in enclosed spaces and with increased numbers of people. The World Health Organisation has advised that the elderly and those with underlying medical conditions are more vulnerable. Upon entering into an agreement to enter the premises used by ELH, or to have Face2Face lessons at a venue of your choice you assume all risk associated with Covid-19 (unless in any way caused by the negligence of ELH). You also agree to: abide by all government guidance aimed at preventing the transmission of the virus (details of which can be accessed via the following link https://www.gov.uk/coronavirus); and follow all directions provided by Elh and its staff. You must not enter the premises used by Elh or attend Face2Face lessons at a location of your choice if you believe that you may have been infected with Covid-19. Failure to comply with these measures shall entitle ELH to eject you from their premises and/or cancel your Face2Face lessons. If you have any questions, please get in touch on info@englishlanguagehouse.co.uk

In submitting this form I confirm that I have read and agree to the above disclaimer. *

Yes No

Please submit this form at least 24 hours before your visit

Submit

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

WHEN YOU VISIT ELH PLEASE

Maintain social distancing at all times.
Arrive and leave at your allocated times.
Bring your own hand sanitiser with you and use this throughout the day.
Wear a mask.
Wear gloves if this is necessary.
Wash your hands after you use the public toilets in the building.
Bring your own pack of sanitiser wipes with you to use if necessary.
Bring your own pack of tissues with you to use if necessary.
Do not share pens, paper, books, tissues etc with anyone else.
Do not come to ELH if you have any Covid symptoms eg a cold or a sniffle, a sore throat, a temperature etc, even if you do not think this is Covid.
Do not arrive to visit ELH without an appointment.

NOTE THAT: There will be hand sanitisers in the building and in the Elh rooms but we advise that you bring your own so that you can guarantee that it is untouched by others and suitable and available for you to use whenever you need.