COVID 19 – SELF DECLARATION
SELF-DECLARATION: This section is for the crew member attending the location to fill out.
Name
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First Name:
*
Surname:
*
Date of Filming:
*
Filming Location:
*
Have you experienced any of the recognised symptoms of COVID-19 within the last 7 days?
High temperature or fever:
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This means you feel hot to touch on your chest or back (you do not need to measure your temperature)
Yes
No
A new continuous cough:
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This means coughing for longer than an hour or three or more coughing episodes in 24 hours. If you usually have a cough, it may be worse than usual.
Yes
No
Loss of sense of smell or taste:
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This means you have noticed you cannot smell or taste anything, or things smell or taste different to normal
Yes
No
Has anyone you live with had symptoms of COVID-19 in the last 14 days?
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Yes
No
Have you come into close contact with anyone who may have been displaying symptoms of COVID-19 in last 14 days?
*
Yes
No
Do you consent having your temperature taken, and to the above personal information being held and processed by CPL Productions Ltd. for the purposes of managing their COVID-19 risks?
*
Yes
No
I will inform a representative of the production immediately if I experience any symptoms of COVID-19.
I will inform a representative of the production immediately of any significant changes to information of the above.
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