Information

The following must, at a minimum, be inventoried per :
Full name:
First name:
Birth date:
Have you suffered or do you still suffer from:
Typhoid: Yes / No
Paratyphoid: Yes / No
Tuberculosis: Yes / No
Contagious skin diseases: Yes / No
If so, which:
Any other infectious diseases: Yes / No
If so, which:


Have you contracted a strange abroad:
For a contagious disease not listed above: Yes / No
If yes, which:

If someone has suffered from the following diseases or conditions within 24 hours before the start of their shift, the must be notified:
Diarrhea
Vomiting
Fever
Stomach pain with fever
Visibly infected areas of skin (burns, cut wounds, etc.)
Runny ear, eye, or nose


The undersigned declares that the above information has been filled in truthfully:
Name:
Signature:
Date:

Associated files

health_declaration.docx

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