Surname, First name*
Relationship with the UB*
Complementary Training Area (Casa Jeroni Granell) Complementary Training Area (El Carmen Building) Complementary Training Area (Torre de la Cruz) Josep Carner Classroom High Mountain Research Centre Baldiri Reixac 2 Building Historic Building Solé i Sabarís Building (CCiTUB) CRAI Depot (Cervera) Faculty of Fine Arts Faculty of Audiovisual Information (UB Sants) Faculty of Biology Faculty of Earth Sciences Faculty of Law Faculty of Economics and Business Faculty of Education Faculty of Pharmacy and Food and Nutrition Sciences (Torribera Campus) Faculty of Pharmacy and Food Sciences (Diagonal Sur) Faculty of Philosophy and Faculty of Geography and History Faculty of Physics and Faculty of Chemistry Faculty of Medicine and Health Sciences (Campus Clínic) Faculty of Medicine and Health Sciences (Bellvitge Campus) Faculty of Psychology Pere Pons Park Humanities and Social Sciences Park (Can Jaumandreu Building) Pabellón Rosa Sports Service Other UB premises Other premises outside the UB
Do you have any of the following risk factors?
(You can select more than one option with the Crtl. key)
None of these risk factors Cardiovascular disease, including hypertension Chronic lung disease Diabetes Chronic renal failure Immunosuppression Cancer under active treatment Severe chronic liver disease Obesity (BMI>40) Pregnancy You are over 60 years of age
Do you have any other illness that is not on the list for which you need treatment and that you think could be incompatible with your working conditions at the current time of the pandemic?*
If yes, please tell us the diagnosis, treatment and your current state of health and we will evaluate it
Do you have any disability that you consider incompatible with your working conditions at the UB?*
If yes, please, explain us your personal situation and we will evaluate it
Details of your current UB on-site activities
What means of transport do you use to get to work?
How long does it take you to get to work?
In what means of transport did you come before the pandemic situation?
What is your usual place of work?
Are your tasks at this moment different from the usual ones and therefore, in your opinion, does the activity present any added risk (other than SARS-CoV2)?
Usual working hours at your workplace
Hours planned and days of presence/work in person at the moment
In the case of PDI, weekly hours of face-to-face teaching planned, both theoretical and practical
Do you have to go to a different place of work during your stay at the UB?*
Do you use any tool, furniture, material that is also used by other colleagues or workers and may represent a risk of contamination?
Is there a cleaning service for the furniture and facilities you use?*
If you do an additional cleaning of the furniture or materials you use, do you have the appropriate products and protection elements? What are they?
If you are alone, do you have regular contact (telephone? face-to-face?) with someone while you are at your workplace in case you have to report an emergency situation?*
Interaction with other people
Do you consider that your work requires at some point to have a close contact at your workplace?* (Close contact: any person who has been in the same place as you at a distance of less than 2 metres for at least 15 minutes without adequate protection.)
Indicate briefly what are the tasks that you will perform in your usual job (on-site and remote work) and that have led you to think that, being vulnerable, represent a risk to your health
I hereby declare that*:
the information that I have provided in this questionnaire is true
I will inform the OSSMA in the event of any change in my situation
Signature of the worker*
(Draw your signature in the box)
As the questionnaire contains medical information, it will be sent directly and only to health personnel at firstname.lastname@example.org. From this address, only technical information will be forwarded to the prevention technicians. Based on the answers to the questionnaire, a medical and technical assessment will be made to determine whether there is any specific condition to be considered.
Right to information regarding the processing of personal data
(1) The responsible for the processing of your data is the General Secretary of the University of Barcelona. (2) The purpose of the processing is to manage the periodic monitoring of the health status of employees. (3) You have the right to access your data, rectify them, delete them, oppose their processing, request their portability and the limitation of processing, in certain circumstances. (4) You may consult the
detailed information on the above-mentioned treatments
I declare that I have read the right to information and I consent to the processing of my personal data in the terms indicated.