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Global Self-Attestation Form
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UK COVID-19 Attestation Form
Amazon employee:
If applicable, please complete this form confirming that you are claiming sickness leave/benefit for a reason which
meets the criteria of Amazon’s policy on special pay related to COVID-19.
Fraud or Misrepresentation
Providing false or misleading information, or omitting material information in connection with any request of
benefits or leave may result in disciplinary action, up to and including termination.
Please carefully consider these definitions, under Amazon’s policy, to receive special pay related to COVID-19:
1. You have been medically diagnosed with COVID-19, on date
or
2. You have been individually directed to quarantine by Amazon related to work place exposure to COVID-19,
on date
or
3. You have been told by your own health care provider (e.g. doctor or physician) that you must be
quarantined related to COVID-19 or you have been contacted by NHS Test and Trace/NHS covid-19 app on
date
, or
4. You believe you must be quarantined due to close contact with someone on date
who has been
confirmed positive or is showing symptoms of COVID-19, (close contact is defined as being within
approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; or having direct contact
with infectious secretions of a COVID-19 case such as being coughed on), or
5. You believe you have COVID-19 because of the recent onset of one or more of the following symptoms since
date
*:
a. A high temperature, this means you feel hot to touch on your chest and back however you do not need
to measure your temperature
b. A new, continuous cough, this means coughing a lot for more than an hour, or 3 or more coughing
episodes in a 24hr period – if you usually have a cough, it may be worse than usual
c. Shortness of breath, at rest and worsening
d. Sore throat, difficulty swallowing
e. Loss of taste and smell (Anosmia), or
(*In case you display these symptoms, please register to get yourself tested for COVID-19)
Attestation
I confirm that I meet the standards for being quarantined for COVID-19 under at least one of the areas listed above
(#1- #5) and have ticked and filled in the [date] to confirm which one(s) apply to my situation.
By agreeing to the statement below, and signing this document, I certify that all of the information above is true
and accurate. I agree and acknowledge that I am expressly prohibited from making any misstatement or material
omission in this request, and that making a misstatement or material omission in this leave request is a violation of
Company policy and may result in denial of benefits and/or disciplinary action up to and including termination of
employment.
__________________________________________________________
Signature
____________________
Date
Effective November 11th, 2020.
The UK Self-Attestation form aligns to the UK Government guidance relating to COVID-19, and as such is subject to change in line with
amendments made by the UK Government.