Covid Questionnaire

Coronavirus Pandemic

Children’s Health Declaration Questionnaire

Given the recent outbreak of the Coronavirus, which is rapidly spreading across the world, Blackberries Childcare is putting some precautionary measures in place to protect the well-being of the staff, children, parents and visitors to the setting.

These measures may sound strict however they are necessary, and we are taking our advice and guidance from Cobra. We are grateful for your co-operation in this matter and appreciate your support.

Have you or a member of your household travelled anywhere inside or outside of the UK, where International, National, or Local lockdown restrictions apply? If Yes, please state the destination of travel and dates to and from the UK. Up to date guidelines can be found on the GOV.UK website.

Yes Country of Origin

Date from
Date to

No I have resided in the UK, Place

Have you or have you been in close contact with a family member, spouse, any individual who has travelled inside or outside of the UK within the last 14 days and to a country outside of exempt list of countries and territories? Information can be found on the GOV.UK website. If Yes, then you must not enter our setting and you must follow the guidance for self-isolation.



Are you regularly meeting with others outside of your own and other households? If yes are you following latest guidance following social distancing and household bubbles?



If No, and you are not following guidance and have attended gatherings of more than 6 people please do not attend our setting.

Are you or your child suffering from a sore throat, persistent cough, shortness of breath, loss of taste and smell or a fever? If Yes, please do not enter our setting and seek advice and follow guidance for self-isolation.



Have you or your child been in close contact with anyone that has been diagnosed with the Coronavirus? If Yes, then you must not enter our setting.



Confirm COVID19 Test Taken
Tick if you have you taken a COVID19 test

Confirm Result is Negative
Tick if Result is Negative

If anything changes then you must please let a member of the management team know immediately.

Childs Name:

Date of Birth:


Parent/Carer Name:


Thank you for your support


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