Working together to maintain a safer working environment Supplier & Visitor Coronavirus Screening Checklist

To help manage a sensible approach to the current Coronavirus outbreak, please complete the questionnaire below as honestly as you can.

Privacy Notice

Kettering Borough Council is committed to protecting your privacy when using our services. Before completing this form, please read the following Privacy Notice which tells you how we use your information, who we may share it with and why. It also details what you can do if you have any concerns and how to request the information we hold about you.

Confirm you understand how Kettering Borough Council processes your information and you are happy to proceed *

I confirm

Your Name *

Organisation you represent *

Work Email Address *

Work Contact number *

Date of planned visit to Haylock House *

Name of business you are visiting *

Name of person you are visiting *

Do you have any of the following symptoms: *

Fever Cough Shortness of breath Headaches None of the above

Have you recently travelled internationally in the last four weeks? *

Yes No

If yes, please list all the locations and dates.

Please include the email addresses of your contact at Haylock House (They will also recieve a copy of this email):

Please tick this box if you'd like to receive a copy of your completed form via email

GDPR / Data Protection Statement

When you submit this form data is sent to Kettering Borough Council who own and manage Haylock House
Your data will be used only for screening for the intended meeting
Data will be deleted following the meeting date
Your data will be used by the Reception staff employed by Kettering Borough Council at Haylock House to help manage visitors to the site
If you add email addresses to the above form your data will also be sent to those addresses for the same use as Kettering Borough Council, for helping manage risks associated with Coronavirus transmission and help delay its spread
Kettering Borough Council will only store data on its secure private servers prior to deletion. Data is not stored in the cloud

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