COVID19 Self Declaration Form COVID19 SELF CERTIFICATION Electrification Construction Services Ltd Unit 9, Wheelock Heath Business Court Alsager Road Wheelock Cheshire CW11 4RQ ECS Ltd COVID-19 Operative Self-Declaration Questionnaire The health and safety of our employees and contractors, clients, families and visitors remain the top priority of ECS Ltd. As the Coronavirus situation continues to evolve globally, we’re asking you to complete this questionnaire to help prevent the spread of or exposure to COVID-19. If you answer “yes” to any questions, we respectfully request you speak with your Manager for advice and follow self-isolation procedures. If you answer “no” to these questions you can continue to work your specified work shift. While at site, we ask you to exercise safe social distancing guidelines, avoid handshakes and abide by current health guidelines to frequently and thoroughly wash your hands-on arrival and departure (if possible) and where possible carry and use hand sanitiser. You must also follow the Client and / or Principal Contractor Safety Arrangements whilst on site. NAME * Mobile or Home Phone Number * Planned Date(s) of Shift(s) - DD/MM/YYYY (If No Shifts Enter N/A) * Date * Operative Signature * signature keyboard Clear Manager / Supervisor Signature If possible signature keyboard Clear Next
