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 outside of the UK within the last 10 days, where International, National, or where Local Lockdown Restrictions apply If Yes, you must not enter our setting. 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 your child been in close contact with a family member, spouse, any individual who has travelled outside of the UK within the last 10 days. Information can be found on the GOV.UK website If Yes, then you must not enter our setting and self-isolate for 10 days from onset of systems or Positive COVID Test taken

Yes

No

Are you and your family following the latest rules and guidance for Tiered System throughout COVID 19, with regards to social distancing, essential travel (work travel permitted), and restrictions to meeting anyone outside of your household.

Yes

No

If no, you must not enter 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. Contact your GP or 111 for further advice.

Yes

No

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 and self-isolate for 10 days from Positive Test being taken.

Yes

No

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:

Setting:

Parent/Carer Name:

Date:

Thank you for your support

 

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