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Covid-19 Health Declaration

I understand that the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which the carriers of the virus may not show not show the symptoms and may still be contagious.
I understand that:

  1. Physical distancing may not be possible while in NEFBA receiving services.

  2. I must sanitise my hands before entering NEFBA

  3. I must make all attempts to cover my mouth and nose in the event of coughing and/or sneezing and then immediately sterilise my hands

  4. I will minimise the touching of common surface/areas

  5. I may be unable to proceed with services at NEFBA if they are deemed unsafe to myself or a staff member

  6. I may NOT bring children or anyone else who does not have an appointment into the Academy.

  7. I understand the staff of NEFBA will do everything possible to minimise the spread of COVID-19, but I will not hold them responsible should I contract COVID-19.


I confirm that:

  1. I am not currently positive for COVID-19

  2. I am not currently having difficulty breathing, have a headache, joint or muscle pain, a fever, a persistent dry cough, a runny nose or a sore throat.

  3. I am not waiting for the results of a laboratory test for COVID-19

  4. I have not returned from an affected area, whether by car, air, sea, bus or train in the past 14 days

  5. I have not been identified as a contact of someone who has tested positive for COVID-19 or been asked to self-isolate by any government agency.

  6. I am not in the high risk category for increased illness or death from COVID-19, including : diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy or over the age of 65

Please note that we are obliged to notify NHS track and trace if circumstances require such. If we report any symptoms among staff or clients, or are contacted by track and trace, we are legally obliged to provide them with your contact details and you may be contacted.

By signing this form, you promise to contact NEFBA immediately if you or anyone in your household develops symptoms associated with COVID-19 within seven days of your practical assessment.

Thanks for submitting!

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