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Visitors self-declaration

COVID-19 SELF DECLARATION FORM

In the interests of the safety of staff, their families and the community, we ask that you complete the following self-declaration before working on/visiting our premises. Your co-operation and support is appreciated.

You will be requested to not enter the building if you answer “Yes” to any of the below questions.

Name *

First Name

Last Name

School *

Name of School Principal *

First Name

Last Name

Date of visit (dd/mm/yy) *

(dd/mm/yy)

Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? *

Yes

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *

Yes

Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2 metresfor more than 15 minutes accumulative in 1 day)? *

Yes

Have you been advised by a doctor to self-isolate at this time? *

Yes

Have you been advised by a doctor to cocoon at this time? *

Yes

Have you visited any of the countries outside Ireland excluding Northern Ireland? *

Yes

Additional Information

Acknowledgement *

I confirm, to the best of my knowledge that I have no symptoms of COVID-19, am not self-isolating, awaiting results of a COVID-19 test or been advised to restrict my movements. Please note: The school is collecting this sensitive personal data for the purposes of maintaining safety within the workplace in light of the COVID-19 pandemic. The legal basis for collecting this data is based on vital public health interests and maintaining occupational health and will be held securely in line with our retention policy.

Name *

First Name

Last Name

Date Completed (dd/mm/yy) *

(dd/mm/yy)

Thank you! Your self-declaration has been submitted.

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Thank you!

Millstreet, Co Cork

tel: (029) 700-87

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Millstreet Community School

Coomlogane,

Millstreet, County Cork,

Ireland

029 70087 info@millstreetcommunityschool.ie

Hours

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