Self-isolation form (COVID-19)
Job role
Band
Team
name
Location (where
employee is based)
Reason for self-
isolation
(please delete as
appropriate)
The employee has symptoms
Someone in their household has
symptoms
Serious underlying health conditions &
has received NHSE letter
Over 28 weeks pregnant
Pregnant (less than 28 weeks) but with a
serious underlying health condition
Name
Contact
Number
Managers
name
Symptoms
(if applicable)
Date when
symptoms began
(either employee symptoms
or member of household)
Cont…/
Is the employee
working from home?
Yes/No
Expected return date
Please send completed forms to bchft.HRsupport@nhs.net
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