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Adult Self-Assessment Form
To ensure the Health & Safety of all people interacting with our club, all members and visitors must
complete this declaration form prior to entering the club grounds.
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* Indicates required question
Name
*
Your answer
Mobile Number
*
Your answer
Email Address
Your answer
Date
*
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DD
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YYYY
Do you currently have, or have you been diagnosed with COVID-19 in the last 14 days?
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Yes
No
Are you awaiting results of a test relevant to COVID-19 or are you waiting to have such a test scheduled?
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Yes
No
Have you or anyone in your household travelled abroad in the last 14 days (with the exception of travel between Northern Ireland and Republic of Ireland)?
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Yes
No
In the last 14 days, have you displayed any of the following symptoms: fever, high temperature, persistent coughing, breathing difficulties / shortness of breath, and / or loss of taste or smell? Or an unusual sore throat, headache or runny nose?
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Yes
No
Do you live in the same household as someone who has displayed symptoms of COVID-19 in the last 14 days or who has a confirmed case of COVID-19?
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Yes
No
Have you been in close contact with someone (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day) who has displayed symptoms of COVID-19 in the last 14 days?
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Yes
No
Have you been in close contact with someone (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day) who has a confirmed case of COVID-19?
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Yes
No
Do you think there is any other way you may have been infected with Covid-19 in the last 14 days?
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Yes
No
Have you been advised by a doctor to self-isolate at this time?
*
Yes
No
Do you have an underlying health condition or have you been advised by a doctor to cocoon at this time? If so, please contact the Covid Officer at 087 9313631.
IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, YOU ARE NOT ALLOWED ON THE CLUB’S PREMISES.
I confirm that the above information is accurate to the best of my knowledge.
I confirm that I will contact the Covid Officer (087 9313631) immediately and before my next training session if the answers to any of the questions above changes.
I confirm that I have read the Club Covid-19 Protocol.
Signature Name
*
Your answer
Signature Date
*
MM
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