Portobello Orchestra Self Certification Form

The following risk categories for COVID-19 patients have been defined by the National Health Service. Please read through them and assess whether you are fit to attend rehearsals. If you are then please sign and submit the form. You may want to seek further medical advice before you proceed.

1. High risk (clinically extremely vulnerable)

• have had an organ transplant;
• are having chemotherapy or antibody treatment for cancer, including immunotherapy;
• are having an intense course of radiotherapy (radical radiotherapy) for lung cancer;
• are having targeted cancer treatments that can affect the immune system;
• have blood or bone marrow cancer (such as leukaemia, lymphoma or
• have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine;
• have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD);
• have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell);
• are taking medicine that makes them much more likely to get infections (such as high doses of steroids or immunosuppressant medicine);
• have a serious heart condition and are pregnant.

2. Moderate Risk

1. People at moderate risk from coronavirus:
   • are 70 or older;
   • have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis);
   • have heart disease (such as heart failure);
   • have diabetes;
   • have chronic kidney disease;
   • have liver disease (such as hepatitis);
   • have a condition affecting the brain or nerves (such as Parkinson’s disease, motor neurone disease, multiple sclerosis or cerebral palsy);
   • have a condition that means they have a high risk of getting infections;
   • are taking medicine that can affect the immune system (such as low doses of steroids);
   • are very obese (a BMI of 40 or above);
   • are pregnant.
2. People at moderate risk of infecting others:
   • work in a health care or other frontline setting;
   • share a household with people who work in a high-risk environment ie frontline/key workers.

3. Low risk

• are under 70;
• have no underlying health problems;
• do not live with anyone at higher than usual risk of exposure to the coronavirus;
• do not work in a high-risk setting themselves.

Declaration

I have read the above guidance and I assess myself as fit to take part in Portobello orchestra rehearsals, and safe to meet with other members, in a Covid-19 secure environment.