Information
The following information must, at a minimum, be inventoried per employee:
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 disease abroad:
For example 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 management 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:
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