Return From Sickness Holiday Questionnaire

Return from Sickness/Holiday Questionnaire Name Foreign Holiday? If so, state countries visited

Question

Yes / No

How long off work?

If in hospital, name it

While on holiday leave did you suffer from or have contact with any of the following?

Typhoid or Paratyphoid Dysentery Tuberculosis Yellow Jaundice Parasitic Diseases (worms, lice, etc.) Any confirmed case of food poisoning Have you suffered from any of the following while away from work??

Chronic Bronchitis with spit Diarrhoea and/or vomiting (2 days +) Skin rash or Skin disease Recurrent boils/septic fingers Discharge from ears Discharge from nose Sore Throat I declare that the statements are true and completed to the best of my knowledge. I understand that it is a disciplinary offence to give false information to the above questions and that I could make myself liable if an incident arise as a result of any such false statement. Signature and date

Sodexo at ConocoPhillips Portman House 2 Portman Street London W1H 6DU